July 20, 2011
Volume 13, Issue 15
Midwifery Today E-News
“Shoulder Dystocia”
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In This Week’s Issue

Quote of the Week

Stress is basically a disconnection from the earth, a forgetting of the breath. Stress is an ignorant state. It believes that everything is an emergency. Nothing is that important. Just lie down.

Natalie Goldberg

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The Art of Midwifery

Cord Care

One simple intervention that has shown promise is cleaning the cord with chlorhexidine. (In developed countries, several decades of using binders and many years of cleaning the cord with alcohol have been found to create problems.) A study in southern Nepal found that babies whose cords were cleaned with chlorhexidine, particularly within 24 hours after birth, had drastically reduced rates of severe infection (75% lower) and death (24% lower).

Cheryl K. Smith
Excerpted from “Some Traditional Umbilical Cord Care Practices in Developing Countries,” Midwifery Today, Issue 91
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Jan’s Corner

Shoulder Dystocia

Shoulder dystocia is one of those complications that can easily lead to the death of a baby and has taken many homebirth midwives out of practice, either through direct experience, or due to the witch hunt in their state. It is important that you as a midwife know everything you can because different techniques work for a variety of situations. Make your list of do’s and don’ts for shoulder dystocia long and thorough.

Since I have written quite a bit on shoulder dystocia in the past, I wanted to share new voices in this editorial and asked the mothers and midwives on my Facebook page to share their stories and wisdom. (The names of the first two moms have been withheld to protect their privacy.) I hope these ideas are of help to you.

Mom One: My second child had shoulder dystocia. My midwife told me I had to stay flat on my back, with my knees as high as I could get them (McRobert’s). I had told her prenatally that I wanted to try the Gaskin Maneuver if a dystocia happened. I was very upset that I was told that I must stay on my back and didn’t have the presence of mind to say, Screw that, I’m going on hands and knees.

She said gravity would help pull him under my pubic bone. I pushed, she pulled, my tailbone cracked (my mom even heard it across the room) and then he came out. He had difficulty breathing for the first hour, I think because they immediately said, “He’s not breathing,” cut his cord and took him across the room to give oxygen. I don’t think his breathing had anything to do with the dystocia, or the cord around his neck, which they pulled over his head before his shoulders were born. I think it had to do with them depriving him of a large portion of his blood supply.

Mom Two: I’m another mom with a good outcome, but poor experience with shoulder dystocia. It was my second birth, a hospital induction. I was slammed flat on my back, my knees were shoved into my ears, and nurse was on top of me, pushing my abdomen, with everyone yelling at me to push.

The OB (I had been seeing a midwife) cut an episiotomy that resulted in a fourth degree injury. My son’s initial Apgar was 3 but he transitioned well to a 7. I, on the other hand, had a repair job that took longer than the entire labor (this was a precipitous, less than one-hour birth). I had a damaged symphysis pubis and returned to the hospital a week later with a postpartum infection that resulted in a five-day hospital stay. My “baby” is now 16 and I still have issues from the perineal injury.

Mom Three, Fran Peceri: My fourth child was “stuck” with shoulder dystocia. His head was out for a long time but the rest wouldn’t follow. My midwife told me to get on all fours, not easy considering his head was there, but they all helped me over. She told me to push, which I didn’t do very effectively at first. She encouraged me to push harder and about three pushes later he twisted his way out and was born healthy and robust. There was no tearing, which sort of surprised me. He was more than 2 lb larger than his sister (born two years earlier) and he had the biggest head I had ever seen, let alone birthed! There was some circumoral cyanosis, which resolved quickly, and his Apgars were 9–10. He nursed soon and eagerly, and I was up and functioning well. I am grateful to Cathy, my midwife, and to Ina May Gaskin, for teaching her techniques to all who will learn. Jordan’s homebirth, even with that bit of drama, was safe, beautiful and memorable.

Mom Four, Andrea Salcedo: I actually had a wonderful shoulder dystocia experience. We had a family-only birth and I was on my hands and knees in a birth pool. After my son’s head was born, I realized after a couple contractions that he wasn’t budging. Barbara Harper always sings a song, “If you can’t move the baby, move the mother. If the baby seems stuck, get the mother up. If you can’t move the baby, move the mother.” So, all I did was lift my right knee forward as if I was going to stand up, and as I straightened my body to sit back, he came out without even needing another contraction. His poor chin was purple for a couple days after birth, but I’m so glad it happened the way it did and that he was born into a very calm environment.

Wisdom of the Midwives:

Erika Obert: I’ve had one true shoulder dystocia in the last five and a half years. It was easily managed, though, as mom was in the birth pool. I very simply had her move from semi-reclined to hands and knees, waited three minutes for a contraction, and applied some very gentle suprapubic support as she pushed and baby came out. As I remember it, I did not even touch the baby himself. He came out wailing and pinked up as if nothing had even happened. Waterbirth makes handling things like this so much gentler. The baby and mom were well-supported by the warmth and static pressure of the water and, as a bonus, she delivered without a tear.

Jessica Bingaman: I’ve learned that difficult circumstances don’t have to become a crisis when training is used with confidence and compassion.

Celesta Rannisi: Standing squat for large babies works well.

Melody Bratti Masi: I like left leg straight behind and right leg tucked into the right armpit.

Marlene Waechter: ‎When discussing shoulder dystocia prenatally, I tell the couple that the head is the largest part of the body; if it fits, so will the shoulders. It’s more like turning a key in a lock, you have to have just the right combo of moves to open it up, but it will open! I also demonstrate how pushing harder just jams the shoulders further into the pubic bone and how changing position frees them.

Krystn Madrine: Have great help. Also, don’t push a stuck baby so hard…purple pushing will not make them come out. Changing the relationship of the baby to the pelvis will.

Savita Jones: I have noticed that shoulder dystocia is less likely when I allow for plenty of time during the “rest and be thankful” stage. After confirming a complete cervix, birthing mothers are often encouraged to push before their natural urge and perhaps before very important rotations and processes are made. I stopped encouraging mothers to begin pushing immediately at complete, and also encourage breathing through a few contractions during second stage. It seems that babies are given more time to rotate their heads, shoulders and bodies through the pelvis.

Jan Tritten, mother of Midwifery Today

Jan Tritten is the founder, editor-in-chief and mother of Midwifery Today magazine. She became a midwife in 1977 after the amazing homebirth of her second daughter. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences around the world, or join her online, as she works to transform birth practices around the world.

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News and Research

Radiation and Gender

A new study concludes that “the leakage of radioactive elements from nuclear tests and power plant accidents in the last 50 years” has been a cause of fewer female births worldwide.

A larger gender gap was reported in the United States and in European Countries after atomic bomb tests in the 1960s and 1970s, and again in Eastern European countries after the 1986 nuclear disaster in Chernobyl.

Researchers believe the higher number of male births, a ratio of 105 to 100, may be caused by damage to X chromosomes in sperm. The study suggests that a similar decline in female births could occur in Japan and on America’s West Coast due to the recent Fukushima nuclear disaster.

“Does radiation skew gender balance by causing fewer female births worldwide?” International Business Times. June 7, 2011.

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Featured Article

Waiting for Shoulders

If we had a time machine and went back to the beginning of human birthing, I imagine we would see a common pattern of delivery—the mom would push out the baby’s head. There would then be a lull in contractions. The baby’s head would restitute (untwist at the neck) and then turn to face the mother’s thigh (as the shoulders rotate); after this the mom would push the rest of the baby out with the next contraction. Having mom push before the next contraction is a very recent invention. The true normal and natural method of waiting for the next contraction ensures the baby’s shoulders are in the usual and best position for birth—the shoulders should descend naturally and rotate with the contractions after the birth of the head. It is time we encourage this natural mechanism.

I researched this phenomenon of “waiting for shoulders” and discovered that most authors are in agreement with me. Consider the following sources:

Practical Obstetrics (1932) “When the head of the baby is born, the mucus and amniotic fluid are wiped away from the nose and mouth and the neck is freed from the encircling coils of the umbilical cord…. Haste should not be employed in the delivery of the shoulders; the latter are generally expelled by spontaneous mechanism.”

Delee’s Obstetrics for Nurses (1904) “After the perineum is stretched so that it seems as if the head may come through, in the interval between pains the patient is asked to bear down a little and the head will come. After a few moments the pains force the shoulders out and then the trunk follows.”

Benson’s Handbook of Obstetrics and Gynecology (1983) “In vertex presentations, the forehead appears first (after the vertex), then the face and chin, and then the neck…. Before external rotation (restitution), which occurs next, the head is usually drawn back toward the perineum. This movement precedes engagement of the shoulders, which are now entering the pelvic inlet. From this time on, support the infant manually and facilitate the mechanism of labor…. Do not hurry. If the strength of the contractions seems to wane, be patient; labor will resume. Once the airway is clear, the infant can breathe and is not in immediate jeopardy. Delivery of the shoulders should be slow and deliberate. The shoulders must rotate (or be rotated) to the anteroposterior diameter of the outlet for delivery.”

Synopsis of Obstetrics (1940) “Delivery of the shoulders: a) Do not yield to the urge to hasten delivery as soon as the head is born…. b) There is usually a lull in the pains at this time. c) Wait until the head rotates externally, which is an indication that the shoulders have rotated internally. There is no hurry as long as fetal color is good. d) When sure that the shoulders lie directly anteroposterior and pains have recurred, delivery may be assisted.”

Even books for the “lay public” speak of “waiting for the shoulders.”

Childbirth at Home (Sousa 1976) “When the head is born, the attendant can suck mucus from the baby’s throat, if the baby is not already crying. With the next contraction, the mother can push gently to rotate the baby’s body. Usually the rest of the baby will then slide out smoothly. If not, wait until the next contraction pushes out the baby’s top shoulder.”

Gail Hart
Excerpted from “Waiting for Shoulders,” in Midwifery Today’s Shoulder Dystocia Handbook

The Shoulder Dystocia Handbook can be purchased here.

Read a new article on shoulder dystocia by Sister MorningStar in the next issue of Midwifery Today magazine. Make sure you receive that issue in your postal mailbox, Choose from one- or two-year subscriptions here.

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Read these articles recently posted from Midwifery Today magazine, Spring 2001:

  • 7 Steps toward Cesarean Prevention—by Judy Edmunds, CPM
    Excerpt: I feel confident that at least most of the cesareans I have been associated with were actually necessary, many even life-saving. Yet looking back over my practice, I can easily pick out scores of women who surely would have had cesareans had they chosen care elsewhere.
  • Midwifery Care for the VBAC Woman—by Gloria Lemay
    Excerpt: Someone asked me what things are done differently with vaginal births after cesarean (VBAC) as opposed to a first baby. Midwives usually reply to this question with a reassuring, Oh, we treat you normally, but there are differences in the two situations that can be distinguished in midwifery practice.

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Bring resources about homebirth and midwifery to your community.

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Birth Wisdom from the Web

Many women do a birth journal following their birth. I felt, as a father, I wanted to document this experience in my own way so I decided to do it via this film…. It was an amazing experience.

Joshua Canter, new father, writer and artist, on the making of his short film about the homebirth of his daughter, Jaya.

The midwifery profession has to come together to protect their brand from the misperceptions that surround it if they are going to be able to increase midwives’ relevance and awareness and connect the many small, grassroots organizations doing work in this field.

Sam Ford, Fast Company blogger

Footage of a chimpanzee being born has shown that the animals give birth in a way that was thoughts to be unique to humans. A team took close-up footage of captive chimps giving birth, which revealed that the newborn emerges from the birth canal facing away from the mother.

— “Chimpanzees give birth ‘like humans,’” BBC News

If you’d like to share a bit of wisdom from the Web, please send a 4–5 sentence excerpt, accompanied by a link, to mtensubmit@midwiferytoday.com.

Conference Chatter: The First Step

The recent Midwifery Today/Home Child Conferences in Moscow, Russia, bore much fruit. Besides the fantastic learning experience, and inspiration it had on all teachers and participants, the medical system was moved to consider the value of natural birth and homebirth. Those involved in the hospital told the midwives that Katerina Perkhova’s work (as editor-in-chief of Home Child) and conferences have lead them to change their birth practices in the hospital. Here is Katerina’s report of their first meeting. More are following. Pray other countries can get that much consideration and respect from Health Officials!

Jan Tritten

photo from Russia
Ruslan Trofimov, Natalia Kotlar, Katerina Perkhova and Mikhail Golovach—MAMA team

The movement for natural birth out-of-hospital in Russia started in the 1970s. Since then whole generations of children born at home have grown up, and so have generations of traditional midwives, who became real professionals in their field, despite the lack of acceptance in society and lack of official status for this profession in Russia.

Both parents and specialists (both traditional midwives and representatives of the state system) had to come a long way before a constructive dialogue was possible. It took more than 40 years before we at last sat down to negotiate and start working together—and it happened on June 20, 2011, in the Moscow City Duma as a part of the work of the committee on public health care.

The head OB/GYNs of Moscow’s administrative districts, representatives of women’s consultation clinics and maternity hospitals, as well as traditional midwives and specialists supporting the development of a professional service assisting in birth out of hospital, participated in the hearings.

Mark Kurtser, head OB/GYN of Moscow, stated that traditional midwives who assist at homebirths have a lot of very positive experience in preparation for natural birth and non-medicated pregnancy and birth care that could not but help influence the work of maternity hospitals and women’s consultation clinics. He showed a video of a waterbirth that recently took place at his medical center. The heads of women’s consultation clinics said during the discussions that they were upset by the fact that parents choosing homebirth consider the doctors in the women’s clinics to be enemies and don’t notice that they have changed a lot and are prepared to change even more, because more and more women want to have natural pregnancies and births.

Of course, it wasn’t easy to sit at the same table and hear each other out respectfully, but both representatives of the state system and traditional midwives were very polite and open to dialogue. All the participants had one goal—healthy mothers and children. The suggestion made by our MAMA organization on the creation of a working committee made up of the representatives of official medicine, parents and traditional midwives was supported by all the participants. The committee has already started work to make homebirth in Russia safe, midwives professional and birth in hospital devoid of aggression.

I think that the main achievement of this meeting was that representatives of the authorities and the medical community agreed that birth is a human rights issue. They agreed that banning homebirth is a dead end in itself, which leads to the marginalization of the movement for natural birth, and that illegal homebirth is not as safe as a planned homebirth with a professional, traditional midwife.

Of course, it’s still too early to speak of the legalization of traditional midwives. We have a long way to go still. But the first step has been made and may it be the start of big changes in both Russia and the world.

Katerina Perkhova

Think about It

When the focus is on the jillion little things that can possibly go wrong, we teach fear and distrust of the body’s innate ability to do its work. We need to stay in the norm and cushion students in their first year of education—with normal birth. We need to remain within the circumference of the “nutrition-plus-exercise-plus-relaxation-equals-outcome” model. If we try to teach the medical model—and especially if we teach this initially—we cannot hope to prepare midwives to advocate [for] and facilitate normal birth.

Alison Osborn, midwife
Excerpted from Midwifery Today, Issue 20
Issue 20 is out of print. Check here for all available back issues.

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Dear Friends,

My name is Laxmi Tamang and I am one of the founding members of Nepal’s first and only nurse-midwife-led independent birthing centre, as well as a founding member of the Midwifery Society of Nepal (MIDSON), established in 2007 and 2010, respectively.

Our birthing centre (http://www.apskendra.org.np/target) is struggling for sustainability because we are not donor funded. During its establishment, each of the 11 nurse members contributed $1333 to set up the birthing centre. We registered it as a social enterprise and have had very good cooperation and collaboration with the government of Nepal.

We provide free maternity care to all women who come to give birth in our centre, as well as a range of sexual and reproductive health services to urban poor families; these include family planning, antenatal care, delivery, postnatal care, immunization and STI treatment and management.

Since May of this year, Julie-Ann Dowdell, an Australian midwife, has been volunteering at the centre, and at the same time carrying out her research on the perspective of consumers, staff and others towards the birthing centre.

We welcome your help and support by volunteering your time during your travel to Nepal. We look forward to hearing from you.

Best regards,
Laxmi Tamang

Read more about MIDSON in the next issue of Midwifery Today magazine. Make sure you receive that issue in your postal mailbox! Choose from one- or two-year subscriptions.

Ministry in Haiti Competing for Funds for New Clinic

We are applying for a grant for building a new maternity center. Click on the link to Giving of Life and vote that we should get it. Also there is a great description of our program written up on the link. Please read and feel free to share this link. http://givingoflife.com/browse/heartline_ministries/

— Joanna Howard

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