January 15, 1999
Volume 1, Issue 3
Midwifery Today E-News
“Shoulder Dystocia”
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In This Week's Issue:

1) Quote of the Week
2) Welcome!
3) The Art of Midwifery
4) News Flashes
5) You Can Get That Baby Out
6) When Does Shoulder Dystocia Occur?
7) Let the Shoulders Birth Spontaneously
8) Epidurals and the Incidence of Dystocia
9) Letters

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1) Quote of the Week:

"I desire to conduct my affairs that if, at the end, when I come to lay down... I have lost every other friend on Earth, I shall at least have one friend left, and that friend shall be down inside me."

- Abraham Lincoln

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2) Welcome!

Welcome to Midwifery Today E-News!

Quick, direct communication is a dream come true for us. There have been many times during the past twelve years of publishing a quarterly magazine that we wished could inform you about something was time sensitive. This format gives us concrete and quick way to reach in case anything interest realm midwifery takes place. As always, continue be dedicated bringing information can use every issue.

Please forward issues of this newsletter to every midwife, doula, childbirth educator and interested parent you know. Our goal is to weave an extensive network of people interested in the midwifery model of care. With it we can "safety net" more and more mothers and babies all around the globe. Modern technology is providing the means--let's take advantage of it! As well, if you have a web page, please post information about this newsletter on it and help us get the word out.

You do not have to be a subscriber to Midwifery Today magazine in order to receive this newsletter, but of course you are always welcome to subscribe. Our quarterly print publication has an impressive history of educating and supporting practitioners and parents of all walks. (If you'd like to subscribe to the _print_ publication, contact inquiries@midwiferytoday.com for information. Send your name, postal address and phone number and mention Code 940.)

Thank you for being part of this important network and for getting the word out. Please email us at mtensubmit@midwiferytoday.com if you have ideas, articles, techniques or news for the newsletter.

- Jan Tritten

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3) The Art of Midwifery

The first shoulder dystocia technique I ever used was brought from Guatemala by Ina May Gaskin. You simply help the mother turn over to a hands and knees position. It is believed that the turning process is what dislodges the shoulder. This technique should also work in reverse. If the birthing mom is on her hands and knees, have her flip over to a semi-sit position. If the baby still does not deliver, have her get into a squat--the position which gives full diameter available for delivery.

Yet another technique is from a nurse-midwife I know who practiced in Africa. When shoulders were stuck, local midwives would move the baby's head up and down as if it were nodding.

- Jan Tritten, in "Wisdom of the Midwives: Tricks of the Trade Volume Two," a Midwifery Today Book

When you encounter what appears to be a stuck shoulder, have your assistant begin calling out the time in 15 to 30 second intervals from the birth of the head. Time has a way of standing still in such situations, and it helps to know how much time has actually elapsed. This could be useful in any emergency situation in which time is of the essence.

- Lani Rosenberger in "Tricks of the Trade Volume One," a Midwifery Today Book

Save $5 when you purchase both Tricks of The Trade Volume I and Volume II. Only $40 plus shipping! Call today to order: 800-743-0974. For more information, visit the links above. Mention code 940 and save an ADDITIONAL $2 when you buy both books. This extra savings offer expires Jan. 31, 1999.

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4) News Flashes

The Gaskin Maneuver

Ina May Gaskin, CPM, teaches the use of a simple maneuver to resolve shoulder dystocia (see "The Art of Midwifery" above). Ina May collaborated with Joseph P. Bruner, MD of the Department of Obstetrics and Gynecology at Vanderbilt University Medical Center, Nashville, to publish a study of a registry of cases Ina May established in which a variety of practitioners used the All-fours, or Gaskin Maneuver. The Journal of Reproductive Medicine published the study in May 1998.

The publication of this article is important because it provides obstetricians with a nonsurgical solution for one of the most feared birth complications. And of special interest to the midwifery world, it is the first time an obstetrical maneuver has been named for a midwife, despite the fact that midwives developed many of the manual techniques used during labor and birth long before there were obstetricians.

- Birthing, Fall 1998

Risks of Shoulder Dystocia Studied

A 10-year case record review was done of all instances of shoulder dystocia in the department of obstetrics and gynecology of Dalhousie University, Halifax, Nova Scotia. There were 254 cases of shoulder dystocia in 40,518 vaginal cephalic deliveries, a rate of 0.6 percent. In these cases, brachial plexus palsy occurred 33 times (13 percent), and there were 13 fractures (5.1 percent). There were no perinatal deaths attributable to shoulder dystocia. The risk was increased with prolonged pregnancy (threefold), prolonged second stage of labor (threefold), mid-forceps delivery (tenfold) and increasing birth weight.

Of the maneuvers used to deal with shoulder dystocia, strong downward traction on the head was significantly correlated with brachial plexus palsy compared with other individual methods of delivering the shoulders. The use of hands and knees position was not assessed.

- Obstetrics and Gynecology, July 1995

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5) You Can Get That Baby Out

Shoulder dystocia is diagnosed when the birthing baby's head delivers but the neck does not appear. The shoulders have failed to enter the pelvis, preventing the usual spontaneous rotation and descent.

When the anterior shoulder of the delivering baby is caught behind the mother's pubic bone and the baby will not deliver past the head, the Woods Corkscrew Method has traditionally been advised. Woods suggested using a principle of physics, that of the corkscrew, to get the baby out. The hands are inserted over the baby's chest and back, and the baby is rotated 180 degrees, bringing the anterior shoulder posterior and drawing the baby into the pelvic curve. Then the baby is rotated back the full 180 degrees, this time delivering the anterior shoulder.

My subsequent experience taught me that in his concentration on the corkscrew, Woods ignored another important principle of physics: friction. My favored technique for shoulder dystocia involves sliding one hand in, along the curve of the sacrum (there is plenty of room there, as opposed to the anterior pelvis) to deliver the posterior shoulder. If that is impossible, disengage the posterior arm, and the shoulder will follow. The baby is turned only enough to bring the shoulders into the anterior-posterior diameter of the pelvis, if that rotation has not already occurred.

Other suggestions for dealing with shoulder dystocia:

First, don't overdiagnose. The rate of shoulder dystocia is 1.7 percent in babies over eight and a half pounds. Very slow delivery of the head, face and chin suggests shoulder dystocia but may not always lead to it. Note the time of delivery of the head. While it is true that complications tend to cluster, if you have experienced shoulder dystocia four times in your last fifty births you are probably overdiagnosing.

When you suspect shoulder dystocia, encourage the mother to push, and be sure her legs are widely separated, drawn up and back, positioned as if she were in a squat. You may apply head traction, gently drawing the head toward the back of the mother's body. This may bring the anterior shoulder under the public bone. Keep the spine straight while applying head traction to avoid damage to the spinal cord. An assistant can apply suprapubic pressure which may dislodge the shoulders. Watch for the neck! If the neck appears, the shoulder is not impacted.

Communicate. Tell the mother the baby's shoulders are stuck and that she must push hard to get the baby out. Tell her you are going to help her and be very clear about what you want her to do.

Changing the mother's position to hands and knees will deliver many babies at this point. If advance of the neck is not seen, slide one hand inside, along the mother's sacrum, and locate the posterior shoulder of the baby. The hand is up inside to the wrist at this point. Traction is made on the arm and shoulder; be careful to avoid the axilla where pressure on the superficial brachial nerve plexus can cause partial or complete paralysis of the arm. If this is not successful, flex the arm with pressure on the antecubital fossa, inside the elbow, and pull it across the chest and out. The most severe shoulder dystocia babies who do not deliver progressively at this point can be worked loose by rotating the now-delivered posterior shoulder and arm up under the pubic bone. The other shoulder comes out through the roomy curve of the sacrum.

- Marion Toepke McLean, Midwifery Today Issue No. 12.

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Learn more about shoulder dystocia at the Midwifery Today conference in Austin, Texas, March 4-8, 1999.

Call or e-mail for your conference program, or download it in .pdf or .zip format.

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6) When Does Shoulder Dystocia Occur?

For infants of nondiabetic mothers, the risk of shoulder dystocia is approximately 10 percent for infants weighing 4,000 to 4,499 grams and 23 percent for infants >4,500 grams. For infants of diabetic mothers the risk is 31 percent for infants >4,000 grams. Given the relative infrequency of both infants >4,500 grams and infants of diabetic mothers, shoulder dystocia occurs in only 2 percent of births, with 47 percent of infants weighing 4,000 grams.

Occurrence of shoulder dystocia should be suspected when infants weigh more than 4,500 grams; when excessive conduction of anesthesia with maternal bearing-down ability impaired; with dysfunctional labor; and with operative vaginal delivery of the larger fetus; or with infants of diabetic mothers >4,000 grams.

- Robert Goodlin, MD in "OB/GYN Secrets," Hanley & Belfus, 1997

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7) Let the Shoulders Birth Spontaneously

When birth takes place under water and when women choose to give birth on all fours, squatting, kneeling or standing, the shoulders are usually born spontaneously a few minutes after the birth of the head. This occurs despite the fact that a "hands off" approach to the birth of the shoulders is common practice at such births, as access is often restricted. In comparison, when women are delivered in a recumbent position, traction appears to be required more often, particularly when the mother has epidural analgesia.

Delivery techniques may actively influence the mechanisms of labor. If traction is applied to the shoulders before they have had time to rotate, it is possible that this interferes with the outlet mechanisms and hinders the spontaneous birth of the shoulders. It has been suggested that in cases of difficulty, the use of traction may only serve to increase the degree of impaction and the likelihood of neonatal injury. If such interventions run the risk of causing difficulties with the delivery of the shoulders and injury to the baby, the common practice of applying traction needs to be questioned. These problems may be reduced, if time is allowed for the shoulders to be born spontaneously, by waiting for a uterine contraction and for the mother to bear down.

Many birth attendants are anxious that, by waiting for shoulders to be born spontaneously, birth will be prolonged significantly and the baby will become asphyxiated. A study was carried out on 100 women and compared an active with an expectant approach to the delivery of the shoulders. The mean time for the birth of the head to expulsion of the body was 18 seconds (range 4-40 seconds) in the active group and 50 seconds (range 9-150 seconds) in the expectant group. In this small study prolongation of the expulsive process in order to achieve spontaneous birth of the shoulders did not compromise neonatal outcome. There was no neonatal birth injury in either group.

It would appear that when there is less interference and the shoulders are allowed time to rotate and are born spontaneously, the posterior shoulder is more likely to be born first. This was the case in the early part of the century when a less intrusive, expectant approach to the birth of the shoulders seems to have been the norm. It would appear that a technique that was initially reserved for cases of difficulty has been gradually adopted routinely for normal births The reason for this is unclear, but it is possible that it was used to hasten birth or possibly because obstetricians, accustomed to using this technique in more difficult cases, began to employ it before difficulties with the shoulders were encountered.

Research to date has associated the use of traction at delivery with injury to the baby. If women were allowed time to give birth to the shoulders spontaneously, there is no evidence to suggest that neonatal mortality or morbidity would be increased and the problems associated with the use of traction would be avoided. It may be more appropriate for women to give birth to the shoulders unaided, and for the midwife to adopt a hands off approach unless otherwise indicated.

- from "A six-year retrospective analysis of shoulder dystocia and delivery of the shoulders" by Vivien R. Mortimore and Mary McNabb, Midwifery magazine, 1998

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8) Epidurals and the Incidence of Dystocia

Texas researchers studied 711 nulliparous women at term with vertex presentations and spontaneous labor. Epidural anesthesia was administered to 447 patients and 264 patients received either narcotics or no anesthesia. There was no significant difference in the number of cesareans done for fetal distress between the groups. Apgar scores and cord blood gases were also similar. The incidence of cesarean section for dystocia, however, was significantly higher (10.3 percent) in the epidural group than for those in the other group (3.8 percent). The numbers remained statistically significant when the following variables were controlled: maternal age, race, gestational age, cervical dilation on admission, use of oxytocin, duration of oxytocin, maximum infusion rate of Pitocin, duration of labor, presence of meconium, and birth weight.

- American Journal of Obstetrics and Gynecology, September 1989.

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9) Letters

Thank you for creating the newsletter. It reads very well, a pleasure.

I am trying to circulate two documents: "A Declaration of the Rights of Childbearing Women" and "A Petition for the Rights of Childbearing Women." They are located in my website, "The Revolutionary Passion of Mothering", and can be found in the "Activism" section in the nav bar.

A year ago I gave birth to my sixth child in a blissfully easy, astoundingly uninterfered-with homebirth. Gloria Lemay is my midwife. My birth story is in "Rape of the Twentieth Century" in the Mother Rites section--my history as well as all I've learned about the cruelty of hospital birth. "Giving Love Back to Birth" describes my journey emotionally from endless giving (I would do all I could to help fingers reach my cervix in pelvic exams, etc.) to dignity in childbirth. I've written two books since the baby's been born; the first floundered but the one I'm just completing feels very right. It is called "Resexualizing Childbirth."

Thank you again for the wonderful newsletter.

- Lora-Lee McCracken

Thanks for a great newsletter. It's up to date and worthy of more than a quick scan. Having moved from a high-tech world in South Africa to semi-retirement in a rural New Zealand town, I have tried to keep abreast of the latest midwifery happenings. That has not always been easy in such a small place. It was a pleasure to glean the latest news from you.

Keep up the good work.

- Jillian Wright
Marton, New Zealand.

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Sponsored by Baby T's Gifts for Families!

Check out our adorable Birth Shirtificates for your new born babies.

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