From MIDWIFERY MATTERS, Summer 2001, Issue No. 89
By Mary Cronk
I HAD A CASE of shoulder dystocia in my practice a few months ago which might be of interest. I certainly learnt from it.
The mother was a student midwife in the middle of her training. It was her fourth baby. 'Jasmin' was a Malaysian woman, small and chubby, height 5'2'', weight at booking 13 st 9lbs (86.6 kg). She was married to 'Jim', a largish Englishman. She told me this was her normal weight and had been similar with the other babies. They have three gorgeous little children aged two four and five. Her history was:
Nadine 1995 gestation 40 weeks, spontaneous onset of labour. Long labour probably posterior position; Ventouse delivery, episiotomy, weight 3 kg, (6lbs 10oz).
Isaac 1996 gestation 39 weeks, spontaneous onset, augmentation by ARM and syntocinon, an epidural was needed and a fetal scalp electrode was applied; 'normal' vertex delivery weight 3.26kg (7lbs 3oz).
Alice 1998 gestation 40 weeks, spontaneous onset, long labour, Pethidine, normal vertex delivery weight 3.35kg (7lbs 6oz).
Jasmin was the youngest of six children and she told me that her mother had had no difficulties having babies.
There were only two problems during the antenatal period. Jasmin put on very little weight but, as she was chubby to start with, she was not unduly worried (weight at term 14 st 6 lbs). We discussed her diet and she made adjustments to ensure that she was getting enough calories, minerals, vitamins, and that her diet was balanced. She was continuing with her studies, travelling to college and to her clinical placements. Her husband and in-laws were very helpful and supportive and she had good childcare arrangements. I was very glad when she took maternity leave from 35 weeks, though she still did not gain much weight. On palpation the baby was growing well, the uterine size increasing normally. The pregnancy did not show very much, Jasmin did not appear to be as far advanced in pregnancy as she was. Friends asked her where she was hiding this baby. She also had an intermittent albuminuria which she said she had had in previous pregnancies. In view of this and the slow weight gain, we consulted an obstetrician. There was no bacteriuria and a 24 hour urine collection did not show significant protein; all blood tests were normal. The consultant, Jasmin and I decided it was not significant and it continued to show intermittently till term.
At term labour started spontaneously at 05.30 but progress was slow, despite strong painful frequent contractions. Jasmin and Jim said that this was her normal pattern of labour but it seemed to me to be longer, harder, and more difficult than I would have expected in a fourth labour. Jasmin coped very well with support from Jim and Hannah her friend who was also a student midwife.
At noon Jasmin had some pushy feelings. We decided on a VE. There was a head presenting about 2 cm above the spines. It felt ROP. There was a rim of cervix about 8 cm dilatation. Unfortunately the membranes ruptured spontaneously during this examination. The liquor was clear, and the fetal heart was satisfactory as it had been throughout the labour.
For reasons that I still do not fully understand, I asked my colleague Andrya to join us as second midwife. I normally work alone, though always with backup available, and Andrya came immediately. I explained that I did not really know why I wanted her but the labour just didn't seem to be 'right'.
Jim and Jasmin again said it was always like this. I do not know to this day why, but I said to Andrya that I thought we might get a shoulder dystocia and we went through the 'fire drill' for this. I know that women who start pregnancies overweight are at a greater risk of shoulder dystocia but she had had three previous babies and had been a similar weight.
Jasmin continued to have involuntary pushing sensations but there were no external signs of full dilatation. At 13.45 I did another VE to get a picture of what was happening. The head was slightly lower; there was still a rim of cervix. It was still ROP. I could feel the anterior fontanelle; it was therefore slightly deflexed. With Jasmin's cooperation I was able to gently assist the head to rotate to an ROA position and the head flexed.
Hannah used aromatherapy oils which helped Jasmin, and following discussion I gave her 50 mg of Pethidine, which also helped. I remained concerned about the long hard labour even though the fetal and maternal observations were all normal.
At 16.15 there were some external signs of full dilatation, which a VE confirmed. I felt moderate moulding and caput, the position was directly OA. As Jasmin had been unable to pass urine for some time, I passed a catheter and obtained 75 ml, not enough to impede progress. The head became visible during contractions. Jasmin tried all the positions for the expulsive stage of labour but found that a deep squat was right for her. As a Malaysian little girl she had squatted, and as woman she could comfortably and easily still do a flatfooted squat.
16.40 the head was born S L O W L Y and - turtled. There was no progress with the next contraction. The chin was jammed tightly against the perineum which was soft and stretchy, the obstruction was not at the introitus.
"Into left lateral, Jasmin," I asked.
A contraction, gentle assistance with restitution, the head turned a little and gentle lateral flexion - nothing.
"McRoberts position."
We all turned Jasmin on to her back with her knees right up practically round her ears. There was no sign of the shoulders freeing - sometimes the McRoberts position alone will free an impacted anterior shoulder, as it brings about a relative change in the relationship of the fetus to the maternal pelvis. It didn't on this occasion.
Andrya then did firm supra-pubic (SP) pressure - she put pressure from the right as the position was ROA. 'Folding' the shoulders thus reduces the bisachromial diameter and assists the shoulders into the oblique diameter of the pelvis. With another contraction, more SP pressure and some traction from me, I could feel that the head was freeing, and the anterior shoulder was born, followed by the rest of a large baby. A few puffs with bag and mask and baby Aisha was breathing and yelling. We all got our breath back.
"That hasn't happened before," said Jim.
Aisha weighed 3.8 kg (8 lbs 6 oz), 1 lb larger than Jasmin's previous babies. I examined her carefully, particularly her clavicles. I wasn't sure but I thought could feel some crepitations over the left clavicle. She seemed to be moving both arms equally, but as I wasn't sure I asked Jasmin's GP to come and give a second opinion. Dr Lewis came out in a short time. Aisha was feeding happily. Dr Lewis examined her very carefully, and said she could not feel anything untoward, but felt that she wasn't experienced enough to give the 'all clear' and advised us to consult a paediatrician the following morning. She phoned the hospital, spoke with the baby unit and arranged for the baby to be seen in the morning.
The family had a good night. Aisha had fed and all observations were normal. Jasmin asked Hannah to take Aisha to the hospital with me. We saw a doctor; he looked rather young to be a Registrar.
"Who are you?" I asked, rather rudely.
"I am the senior house doctor," he replied.
"We'd expected to see a Registrar."
"I'm very experienced. Can I examine this baby?"
He made a very thorough examination and pronounced himself absolutely sure that this baby was fine, and that the clavicles were intact. I muttered something about an X-ray but he said he did not think there was any reason to subject this well baby to unnecessary radiation. I agreed with him. He did offer to get the Registrar if we insisted, but as he seemed so confident that all was well, we took the baby home to her waiting parents, with the good news that there were no problems.
Late in day 2 and into day 3 Aisha was becoming mildly jaundiced; that's not unusual. On day 4 jaundice was present but still not very deep. On day 5 we thought the jaundice was beginning to fade. Aisha had been put in as much daylight as was around in December. On day 6 the jaundice was definitely fading; I did the Guthrie test and thought of taking more blood for SBR but the jaundice was fading and I did not feel justified in pricking the heel again. Aisha was alert and feeding well.
We decided to give the family a day off from my visits on day 7, and I visited early on day 8. A bright orange baby was looking at me. I did not need an SBR to tell me this baby needed to go under a light and soon. A quick phone call and Jasmin, Aisha and I went to hospital. The SBR was 428 with PCV of 63 and Aisha was under and on top of a light. Jasmin stayed with her and she responded well.
But why did this baby, whose 'physiological' jaundice was fading, suddenly become deeply jaundiced? Absorption of bruising? But she didn't have any cephalhaematoma or any other visible bruising, did she? Could there be invisible bruising? We talked to the Registrar and had the clavicles X-rayed before Jasmin and Aisha left the baby unit. There it was - a clean fracture of the left clavicle. I thought back to the birth. The shoulder had freed so easily with the SP pressure, that Andrya and I had actually asked ourselves if this had really been a true shoulder dystocia.
I discussed the case with my sensible, supportive, highly experienced, Supervisor of Midwives. She reassured me that we had taken the correct steps, though I should possibly have insisted on the baby being seen by a Registrar on day 1. I feel that this was a helpful criticism. I had recently been to a talk on bullying of junior staff and, as a fairly mature, bossy midwife, I had been too reluctant to be assertive with a young junior doctor. On reflection I am sure that I could have found a tactful way to get a more senior doctor to examine Aisha. On discussing the situation with Jasmin she said that she felt almost relieved by the news of the fractured clavicle, as she had been thinking of all the other sinister causes of late and severe jaundice.
All is well. Jasmin and her family are thriving. Aisha is gorgeous. She is the first baby that Jasmin has successfully breast fed for any length of time. Jasmin is returning to her midwifery training soon and is working out how she can combine nursing Aisha as much as possible with being a student midwife.
Shoulder dystocia is a rare but potentially serious condition. 50% of cases have no identifiable risk factors. There had been nothing to alert me in the antenatal period, but concerns during the labour were enough for me to call a second midwife. I had talked to Andrya about the possibility of shoulder dystocia, but I hadn't been able actually to identify what exactly I had been worrying about.
I do not believe in intuition - I think that what we call intuition is a mixture of experience and putting two and two together. I am very glad that I called Andrya I am very glad indeed that I had done the ALSO (1992) course and that we had rehearsed the 'fire drill'.
15% of cases of shoulder dystocia develop Erbs palsy; 8% have clavicular fractures (Etches and Klein, 1995). According to Dewhurst (1987), Erbs palsy can be permanent; clavicular fractures heal without treatment and cause no permanent problems. As such they are an acceptable complication of the treatment of shoulder dystocia.
Mary Cronk
www.marycronkmidwiferyservices.co.uk
Advanced Life Support in Obstetrics (ALSO) (1992). American Academy of Family Physicians, Kansas 1992.
Etches D and Klein M (1995). Accoucheur vol2 no2 May 1995 reproduced in MIDIRS Digest (Mar 1996).
Dewhursts Textbook of Obstetrics and Gynaecology (4th edn) 1987 edited Whitfield 381-382.
This article was originally published in Midwifery Matters ISSUE 89 Summer 2001, p8-9
LW updated February 4, 2005