By Louise Walker
TRUE SHOULDER DYSTOCIA is described as any birth in which manoeuvres in addition to lateral flexion and episiotomy are required to birth the baby (Resnick, 1980). In an attempt to predict and possibly to prevent shoulder dystocia, maternal risk factors have been extensively studied. These factors include diabetes, obesity, multiparity, postdates, previous history of macrosomia (> 4000 g) and macrosomia in the current pregnancy. Unfortunately, the result of applying these antenatal risk factors is a rise in the number of unnecessary caesarean sections - almost half of the cases of shoulder dystocia occur in infants weighing less than 4000 g (Enkin et al, 2000).
All midwives dread the warning signs in labour of a possible shoulder dystocia but with prompt action and appropriate intervention disastrous complications are reduced. I would like to share with you two personal experiences around shoulder dystocia, which reflect different approaches. In both births the outcome were good for mum and baby.
A call had come from the community that a woman was being transferred by ambulance in established labour. There had been shoulder dystocia in her previous delivery of a l0 lb+ infant and, on palpation, this baby also seemed very large so she had been advised to have her baby at a consultant unit. When the ambulance arrived and I could tell just by her body language that she was progressing quickly, so I did not leave her.
When Jane got up from the wheelchair she took up a standing position by the bed, I briefly asked her how she would like to birth her baby. She replied that in the standing position she was more able to cope with her contractions and it seemed the most natural position for her. Jane was aware of the risk of shoulder dystocia because of her previous birth. I told her that I was happy for her remain in this position and that if I was at all concerned with the birth I would tell her and she could move, if necessary. So I left her in this position whilst I got a few things ready in the room although I felt that the core midwife and the doctors would not be happy for Jane to stand.
Within 10 minutes of being in the room Jane's membranes ruptured and she was beginning to push so I called for a second midwife. The midwife co-ordinating the labour ward came into the room and I took a sharp intake of breath and waited for the criticism but to my amazement she didn't say anything, she just raised her eyebrow. Jane was pushing well with the contractions and it didn't take long for the head to become visible. I had a bean bag to the side of me which I placed under Jane so I could lay the baby on it. The baby advanced well and Jane beautifully birthed her 11 lb 12 oz baby girl into my arms with an intact perineum.
When I left the room I was ready for the questions from the doctors. Thankfully, they had remained outside the door; I think their presence in the room would have had a detrimental effect on Jane's ability to successfully birth her baby. I know that they were horrified that I had 'allowed' her to give birth standing up. My student had returned from the ward and witnessed the doctors' dismay at their lack of control. What if there had been a shoulder dystocia? How would we get her into McRoberts?
My rationale was that Jane's body was telling her to remain upright, she had had a previous shoulder dystocia of a smaller baby whilst being made to birth on her back. Had this been true shoulder dystocia or was it a case of 'bed dystocia'? (Mashburn, 1988). From the standing position I felt it would not be a problem to ask Jane to move to an all-fours position on the floor if shoulder dystocia had occurred, from where she could have rotated on to her back if McRobert's and suprapubic pressure were needed.
Looking at the antenatal risks described by Lee (1987), Jane had a number of the predisposing factors. Namely, prior history of macrosomia (+ l0 lbs), she herself was a big build, her pregnancy was postdates and it was not her first baby. It has been suggested that once a woman has had shoulder dystocia it may be prudent to manage subsequent births with a caesarean section. However, does the presence of such risk factors indirectly cause shoulder dystocia by influencing the management? If the doctors had managed Jane's labour she would have had continuous fetal monitoring, she would have laboured on her back with an epidural and she would have birthed her baby in lithotomy. We know that the lithotomy position restricts posterior movement of the sacrum, which in turn narrows the outlet of the pelvis and the presence of IV lines and CTG cables restricts any further manoeuvres (Gaskin et al, 2001).
My second experience was when I was caring for a woman labouring with her third baby. Sam was progressing very well. She had had two normal births a number of years ago with average sized babies. Sam was mobilising during the contractions and coping with gas and air. Her membranes ruptured spontaneously and the urge to push became stronger and stronger. At this point Sam wanted to get on to the bed and she took up a semi-recumbent position. The baby advanced fairly slowly for a woman who had birthed before and I sensed that something was not quite right so I suggested that Sam should try an all-fours position but she did not want to move.
It took a number of contractions to push the baby's head out and there was distinctive 'turtle necking' visible so I called for help. One attempt at lateral flexion did not move the baby so Sam was manoeuvred into McRobert's position. Another contraction and Sam's baby had still not been born. As I assessed the need for an internal manoeuvre I could feel the finger tips of the posterior arm, I extended the arm by easing the hand pass the head and the posterior shoulder swept the perineum, the rest of baby followed with no problems and in good condition.
This experience highlighted a dilemma for me as I had come to believe that a woman would adopt a position that would benefit the birth. Jane's labour and birth had reinforced this belief, however Sam had been labouring standing up with good progress yet when she wanted to lie down the birth slowed down. Would there have been shoulder dystocia had she remained upright for the birth? I talked with Sam at length after the birth and I asked her why she wanted to give birth lying down. She said that that is how she had always done it therefore it was the natural thing for her to do, she also added that maybe if I had been more insistent she would have moved to all fours!
Has the medicalisation of childbirth, getting women to lie down to birth, increased the number of births complicated by shoulder dystocia? Women are constantly given the impression that they should give birth lying on the bed. I know that if the anterior shoulder gets impacted on the symphysis pubis and rotation of the shoulders is prevented then dystocia can occur, no matter what position the woman is in, but surely the incidence would be less if women labour and birth in a position that does not restrict the pelvic outlet?
On a personal level, even though I work in an environment where continuity of carer, case holding and one-to-one midwifery is not being practised, I will be aiming more consciously to counter the traditional misinformation that women should lie down to labour and give birth. If I had had more contact with Sam during her pregnancy maybe her birth experience could have been very different.
Louise Walker
Enkin M, Keirse M J N C, Neilson J, Crowther C, Duley L, Hodnett E and Hofmeyr J (2000). A Guide to Effective care in Pregnancy and Childbirth (3rd edn) Oxford University Press.
Gaskin I M, Meenan A L, Hunt P and Ball C A (2001.) 'A New/old Maneuver for the Management of Shoulder Dystocia'
www.thefarm.org/lifestyle/dystocia.html
Lee C Y (1987). 'Shoulder dystocia', Clinics in Obstetrics and Gynecology, 30, 77.
Mashburn J (1988). 'Identification and management of shoulder dystocia', Journal of Nurse Midwifery, 33, 5.
Resnick R (1980). 'Management of shoulder girdle dystocia', Clinics in Obstetrics and Gynecology, 23, 559.
This article was originally published in Midwifery Matters ISSUE 89 Summer 2001, p8-9
LW updated February 4, 2005