The Birth Beat : stories, articles and instruction for the modern midwife
Panic and fear arise in the hearts of many midwives and doctors when they think of shoulder dystocia. And many have a strong desire to teach everyone else how best to manage the situation. Yet for others, the same topic creates a feeling of dismay at the over-diagnosis, and frustration at the needless interventions that are forced on so many normal births.
Well, for starters there are multiple scenarios that can occur during birth, all labeled the same thing: shoulder dystocia. And birth itself looks radically different depending on the birth environment. As Ina May Gaskin reminds us, “physiologically, birth doesn’t happen the same way around surgeons, medically trained doctors, as it does around sympathetic women.” Although less discussed in the main-stream population, the reserves of the baby during birth (and during a dystocia) are directly correlated to the mother’s nutritional history, habits and status – but that’s a topic for another article.
The Finer Points
I encourage midwives to use the terms below when charting at births and reporting at peer review because it’s more accurate and ultimately helps the woman’s next care provider treat her according to real risk instead of perceived fear.
1. Normal Spontaneous Vaginal Delivery (NSVD) is any birth that completes on the mother’s own power, or on her own power with midwife’s suggestions, and does NOT result in a depressed baby (even if the baby is on the perineum for quite a while).
2. NSVD complicated by a shoulder dystocia of ___ minutes, resolved using ________ techniques is any birth that requires midwives’ hand maneuvers and direction to effect delivery. The timing should be assessed from the time the midwife realizes that she needs to physically intervene, NOT necessarily for the whole time the head is out.
Using the above definitions presupposes a few components of a midwife's skill level and ability to risk-assess. First, she must have skilled assistants who record accurate times of all major events. Second, she must know how to assess and interpret fetal status throughout labor to know which babies should be risked-out of homebirth for fetal distress, and how urgently to effect delivery, if imminent. Third, each midwife must have current, accessible, and practiced skill in resolving dystocia. The fourth and final qualifier is that she must be skilled and able to direct a practiced Neonatal Resuscitation Protocol (NRP) response with enough people to continue the effort until Emergency Medical Service (EMS) arrives. Sometimes this means continuing NRP all the way to the hospital since the Emergency Medical Service NRP skill is not uniformly proficient around the country, as many midwives have reported. Additionally, because of this last definition, it reasons that out-of-hospital birth should not be attempted in areas where the distance to the hospital (EMS to the home) is greater than the time the birth team could sustain effective neonatal resuscitation protocol.
Most importantly, because there suddenly becomes two patients at birth, every resuscitation effort requires every midwife team to simultaneously manage the maternal postpartum. IT IS ESSENTIAL TO TAKE ENOUGH SKILLED PEOPLE TO EVERY BIRTH, so that every emergency can be handled appropriately.
There are predictive conditions or risk factors for shoulder dystocia such as:
The incidence of shoulder dystocia is generally reported to be between 0.3 % and 1.5% with scattered reports listing values both higher and lower. The "true" incidence of shoulder dystocia, however, is very much dependent upon how it is defined, how it is reported, and the characteristics of the population being measured. For instance:
Lerner goes on to say, 'how one defines shoulder dystocia, of course, affects its reported incidence. Some obstetricians will only report a delivery as involving shoulder dystocia if they had to employ specific maneuvers to deliver the baby's anterior shoulder. Others will record shoulder dystocia if there is ANY delay in the emergence of the shoulder following delivery of the head. In some cases, a physician will only record shoulder dystocia when a fetal injury has occurred. Finally, the characteristics of the delivery group being measured will affect statistics on shoulder dystocia. A study evaluating the incidence of shoulder dystocia in a population with larger than average babies, or higher incidence of diabetic mothers, will have a much higher reported incidence of shoulder dystocia than if the population were a general one containing a more representational sample of both small and large babies and the normal percentage of mothers with diabetes." The same variations may change the numbers for the homebirth population vs the obstetric population. The bottom line is, we don’t actually know the rate of incidence. Most homebirth midwives report a higher rate than 1% and so we must be prepared for it at every birth (yes, even at ‘roomy’ multips births with no risk factors).
Even if we don't know exactly how often it occurs, we can tell when a dystocia is occurring. Let me first say that I am a proponent of the old midwifery adage, "no intervention in the absence of complication'. A brilliant phrase as long as we truly understand what constitutes a complication. In a normal second stage labor, baby makes distinct, consistent progress. Every push moves the baby a measurable amount, although he may normally retrace his steps many times before the head steps out of the perineum. Progress over time, of course, is an individual, subjective assessment. And interestingly, we aren't great at this assessment while continuously supporting a laboring mum. One more reason I argue for a robust midwifery team allowing the primary to come and go from the actual delivery room (even at homebirths) so that she maintains the necessary perspective to make these assessments. Dysfunction as it relates to the birth of the shoulders is when the normal forces applied to birth the head no longer create the same action. Obviously, a primary midwife should NOT come and go while waiting on the shoulders to deliver. Instead, we must be familiar with this woman's pushing ability and style (having just witnessed her birth her baby's head) and expect the same amount of force will efficiently deliver the rest of her baby in the next contraction - If it doesn't, then action is needed. The specific action and techniques and what order to apply them in is the topic of many workshops and a topic for another blog post.
Interestingly, the 'common law' of midwifery, i.e. that birth of the shoulders happens the contraction after the birth of the head, isn't a universal obstetric notion. Dr. Leslie Iffy, a Maternal/Fetal Medicine specialist in New Jersey and a veritable expert on shoulder dystocia who passed away last year after a 43 year career in obstetrics, wrote an interesting paper in 2015 entitled, "Epidemiologic aspects of shoulder dystocia-related neurological birth injuries". In this paper he and his co-authors conclude, "Incidents of shoulder dystocia began to escalate in the USA during the 1980s, shortly after the introduction of "active management" of the birthing process. This new technique replaced a conservative philosophy which had recommended abstinence from intervention on the part of the accoucheur. The authors consider the interventionist approach largely responsible for the exponential increase in the rates of shoulder dystocia in the USA. They recommend adherence to the traditional method of delivery on the part of obstetricians in Europe and elsewhere."
Active management of the actual delivery was first proposed in the 1976 edition of Williams Obstetrics, whose major authors were Pritchard and McDonnell. This technique, called by some the “one step” technique, recommends attempting to deliver the infant’s shoulder immediately after the birth of the head. Prior editions of the Williams textbook (1961), whose major authors were Eastman and Hillman, wrote to expect that the shoulders would emerge in the contraction following delivery of the head—the “two-step” technique. Iffy's assumption as to not only the reason for the marked increase in brachial plexus injury's, but also the increase in the rate of shoulder dystocias in general. This may indeed be the result of a nation of obstetricians adopting a technique that, at best rushes the process, and at worst, creates the very complication it's attempting to prevent by impacting the baby's shoulder before its had the time to restitute on his own. Time seems to be fairly irrelevant in predicting the need for intervention as well as the outcome of babies who do experience dystocia. Instead, midwives can distinguish between normal and abnormal by lack of normal progress of the birth of the head and/or the first expulsive efforts of the shoulders, abnormal fetal head coloring, gasping or any respiratory effort before birth, and the 'turtle sign'.
As more and more women choose to birth out of the hospital free of the often-arbitrary policies and procedures of the obstetrical model, we midwives are given a broader depth of experience in our practice of the profession, especially those of us who lean towards a woman-centered, hands-off practice-model. Simply stated, we create opportunities to view physiologic birth and draw conclusions about complications and intervention from as pure a view as possible. In my experience, there are three distinct types of shoulder dystocia. I have labeled each based on the increasing speed with which the provider needs to intervene.
The Three Types
1. Non-Emergent Shoulder Dystocia
A non-emergent dystocia is the least dangerous for baby. It occurs because baby is indeed stuck – hung up on the pubic bone, ischial spines, or coccyx - but he has not been and is not depressed in any way. This is why we can work hard to get a baby out that is really stuck, but continues to have good color, and either needs no resuscitative efforts, or recovers after just some stimulation and a few breaths. This baby could be stuck because of his own position or because of the shape of mom’s pelvis, but he is NOT compromised. Of course, without effective, timely action, this scenario can change rapidly. He does need help like all babies in a dystocia, but he doesn’t start out struggling. I call this non-emergent because it’s truly not an emergency; baby is not struggling, venous return is good, placental function is optimal, and baby is no more stressed with his head out then he was during the whole time his head was in the pelvis. Many midwives have stories that their colleagues react to with disbelief, of how long it took them to free a baby. They report 6, 8 or 12 minutes on the perineum - ‘who then are totally fine!’ These stories are examples of this first type of dystocia - these babies truly are fine – just stuck. Take quick action to deliver this baby, but don't be surprised at how well it goes.
2. Emergent Shoulder Dystocia
An emergent shoulder dystocia is essentially the birth of a compromised baby who is slow to deliver at the shoulders. Babies play a huge role in their own births, moving, pushing, and arching themselves out. It's one reason why full-term, healthy, unmedicated births generally go well in any setting. When a baby has lost reserves (either because of placental insufficiency, cord compression, undiagnosed Intera-Uterine Growth Restriction (IUGR), a deteriorating uterine environment with chorioamnionitis or uterine infection, or some other cause of fetal distress) the baby stops fully participating in his own birth. Consequently, descent, rotation, flexion, and synclitisim all become affected by his lack of muscle tone and/or muscle movement. Expulsion of the head is achieved with maternal power while baby just sits there unable to restitute or push himself down and out. This type of birth is an emergency before it even starts. This baby needs resuscitative efforts as soon as possible, evidenced by low Apgar scores at birth. Many of these births are correctly identified before the birth process and transported to a hospital for fetal distress. If not, then these are the babies that are slow deliveries of the head, are frequently tied up in their cords, are relatively 'easy' to deliver once you take action to assist the delivery, but who need a lot of resuscitative efforts. They aren’t actually stuck, but are frequently descending into the pelvis in funky positions because their muscle tone is flaccid due to being compromised. They are floppy and out-of-fight to get born. They need help – STAT.
3. Catastrophic Shoulder Dystocia
Catastrophic shoulder dystocia has the potential for being exactly that. These births are the result of a stuck baby who is already compromised. We midwives want to do everything in our power to identify and risk-out these babies before the birth occurs, but we also need to train for these scenarios religiously. Preventing this type of shoulder dystocia is the motivation behind all of the fear and panic that surrounds shoulder dystocia in our culture. Watching a baby expire while you’re powerless is a terrifying scenario. Fear of these births and babies are the reason for C-sections for big babies and dysfunctional labors. It’s also the reason for all manner of interference at normal births. If you are unlucky enough to be the midwife at a catastrophic shoulder dystocia, please seek support and counseling right away. We need you - wonderful, hardworking, traumatized midwife - to come back from your harrowing experience ready to teach and counsel others. These are the babies who potentially spend weeks in the NICU, have broken arms, nerve injury, paralysis, or they simply do not make it. If you happen to have a long, complicated, difficult dystocia that then needs a long, complicated, difficult resuscitation, AND you have a baby who lives without complication or who you never even had to transport, thank your lucky stars; you just won the midwifery-lottery.
Right now, the major flaw with this view of shoulder dystocia is that the only way to categorize these births is after the fact. We have no way to definitively assess which babies/births are at risk for which type of dystocia beforehand. But, we do have clues, and we do have an increasingly savvy midwifery skill level nationwide.
So, what’s a midwife to do?
First, become an expert in fetal surveillance assessment. Like, seriously! Understand how to accurately assess baseline throughout labor, know how to tell if baseline changes, how often to listen, how long to listen, when to listen. Know how to tell the difference between early, variable and late decelerations. Importantly, transfer all Category II and III babies – believe me, it’s worth it - even if there a few mamas who go on to deliver vaginally without meds in the hospital (like this is a bad thing)– and even if they are miffed that they didn’t get ‘their’ homebirth. Homebirth midwives only take care of low risk clients, and the only babies you can definitively say are low risk are Category I babies.
Second, practice all the ways - know every possible technique to get a stuck baby out – take all the workshops, practice with your friends, practice with your students, practice in your sleep. Make up new ways to move stuck babies. And run role plays with a good mama-actor so that you remember to tell her what you’re doing. So often we practice sticking our hands inside a mannequin forgetting what that would actually feel like and how important it is to communicate with your client so hopefully she doesn’t need therapy to recover from her ‘birth rape’ as well as the emotions of watching her floppy baby be resuscitated.
My third recommendation is to practice NRP often. Don’t just recertify every 2 years; actually know it by heart! Like backwards and forwards – like you can explain it at 3am to your green student until she gets it. And if the new NRP is throwing you – take a Helping Baby’s Breathe workshop. Practice – run scenarios in your head – run role plays in your midwifery practice – talk case studies until you can do it in your sleep. Invest in a good pulse ox monitor (Mossimo Rav 5 is the best). If you have the wherewithal to get the baby out, you must be able to get him breathing! The reality is, if you practice long enough, you are likely to attend a birth or two or three where you really can’t get a baby breathing – but don’t let this be because you don’t know what you’re doing.
And lastly, relax. You really can take comfort in the fact that you are a homebirth midwife which means you take care of the creme-de-la-creme of birthing mothers. On the whole, there is no group of pregnant women more motivated to have a healthy, safe, beautiful experience in the whole world. She will leap when you say leap – she will do all the things you suggest, even eat the gelatinous throw-up that is soaked chia seeds. Your clients will grow the biggest, healthiest, strongest babies of any in the world. Those babies really do instinctively know how to get born – they even help. And because you are a badass midwife who knows her limits, and you listen to your heart - you really will risk-out all the mamas/babies who aren't meant for you. Relax, because it’s really not solely your job to deliver healthy babies. Delegate a whole lot of the work back to your mamas. Have a comprehensive prenatal program that helps bring them along the path of health and wellness as far as they can possibly go. Inspire confidence – exude confidence – model confidence. We all birth better (or do anything for that matter) when we believe we can. Belief, most simply, is a combination of thought, feelings and actions. Think about how to resolve dystocias,, feel into all the feelings, and when in doubt - always take action. Believe YOU can handle it, and so will she.
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