This article is for informational purposes only & not intended to be taken as medical advice
Topics of Discussion in this article:
Understanding Provider Role/Prevention in Shoulder Dystocia
Understanding the variations of Shoulder Dystocia
Promoting Optimal Birth Practices
Outdated Maneuvers vs. Updated Pelvic Mobility Protocols
Birth Tub Influence/Optimal maternal positioning
Functional Physiological Birth System
Childbirth is a miraculous and natural process, especially when low risk & left to it's own physiological nature, but occasionally, certain complications can arise. One complication is shoulder dystocia, a situation where the baby's shoulders become lodged in the brim, mid cavity or outlet of the mother's pelvis during delivery.
Shoulder dystocia represents a significant physiological challenge, impacting the long-term well-being of both the mother, baby, and the delivery team. This underscores the critical need for proficient and contemporary care to properly diagnose and manage this condition effectively. Frequently regarded as a medical issue, the updated approach to this complication involves recognizing it as a physiological challenge, necessitating an understanding of the dimensions of the pelvic space related to maternal positioning and the fundamental movements of the fetus during birth.
While shoulder dystocia can occur due to various factors, it is essential to explore how healthcare providers' may not be fully educated on prevention, root causes and dystocia variations, which lead to influence & interference during labor and delivery, contributing to this condition & hindering physiological resolve.
The pregnant mother is often exclusively attributed with the responsibility for the root cause of their experience:
Fetal Macrosomia: Larger baby size can complicate passage through the birth canal.
Maternal Diabetes: Increases the likelihood of larger birth weights and shoulder dystocia.
Post-Term Pregnancy: Babies beyond due date might have higher birth weights, raising risk.
Maternal Obesity: Obesity is linked to larger babies and elevated shoulder dystocia risk.
Multiparity: Multiple pregnancies can lead to pelvic changes and increasing risk.
Maternal Age: Older mothers (above 35) might face a higher risk of shoulder dystocia.
Previous Shoulder Dystocia: History of shoulder dystocia increases chances of recurrence.
Induced Labor: Labor induction, especially with pitocin, can intensify contractions and risk.
Assisted Reproductive Techniques: Conceived via assisted methods might lead to larger babies and risk.
Short Maternal Stature: Short stature can increase risk of shoulder dystocia.
It's essential to recognize that attributing the root cause solely to the pregnant mother oversimplifies the situation. Research indicates that healthcare providers also play a role in contributing to compaction, as well as potential injury and trauma while attempting to resolve complications. The complexities of childbirth involve a collective responsibility, where both mothers and providers need to be well-informed and equipped to ensure safe and effective outcomes.
It is crucial to recognize that there are multiple variations of shoulder dystocia, which can occur in different parts of the pelvis: including the brim, mid-pelvis (cavity), or the outlet.
Unfortunately, variations of shoulder dystocia are often overlooked in emergency training, with a predominant focus on the symphysis pubis scenario - Many professionals are only taught to vaguely recognize "Mild, Moderate or Severe" signs of SD, without the proper training to diagnose the variations or root cause. This misunderstanding can lead to ineffective actions and potential harm to the baby or mother. We aim to shed light on the importance of understanding different types of shoulder dystocia and the need for comprehensive emergency training to ensure safe and effective prevention-management.
We will delve into how certain provider practices that allow limited space for the baby to maneuver, closes the outlet and compacts the coccyx, sitz bones as well as the sacrum can inadvertently hinder the completion of fetal cardinal movements or further compact the pelvis, potentially leading to shoulder dystocia & the waterfall of intervention through the lack in full spectrum training around each SD variation, maternal position & outdated use of resolving protocols.
The Neurology of Birth Physiologically and Hormonally are respectfully predictable and trustworthy when we do not interfere with Gods role & design
Labor is not a roller coaster awaiting to derail & Mothers + Babies are not along for the ride as passengers without a role in the outcome "A baby can become stuck in any part of the pelvis; The brim, the mid-pelvis (cavity) or the outlet. Unfortunately variations of shoulder dystocia are generally ignored in emergency training, and instead the focus is on the symphysis pubis scenario. This misunderstanding can result in problems with resolving a shoulder dystocia as particular actions are ineffective for particular types of shoulder dystocia and can lead to provider caused injury to the baby or mother." Source Dr. Rachel Reed of Midwife Thinking | Shoulder Dystocia: The real story | Visit her full Shoulder Dystocia training: https://www.google.com/amp/s/midwifethinking.com/2015/05/13/shoulder-dystocia-the-real-story/%3famp
The baby's ability to rotate their head & shoulders in synchronization with the unique space made available by mobile non-compacted maternal pelvic dimensions aids in navigating this narrow passage, preventing or resolving shoulder dystocia.
Understanding Fetal Cardinal Movements:
Before discussing the variations, root causes, contributions and resolutions to shoulder dystocia, let's briefly review fetal cardinal movements. These movements occur as the baby navigates through the birth canal (Pelvic floor muscles, ligaments and bones, optimizing their passage.)
The seven cardinal movements include:
Engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. These coordinated movements allow the baby to navigate the pelvis and facilitate a smoother birth.
Provider Role and Shoulder Dystocia:
Unfortunately, certain labor and delivery positions & protocols encouraged by healthcare providers can inadvertently contribute to shoulder dystocia. One example is the use of the lithotomy position, where the mother lies on her back with her legs in stirrups. In this position, the outlet of the pelvis is compressed, closing the space and reducing the potential for optimal fetal positioning and fetal cardinal movement through-out each phase of labor leading up to pushing.
Additionally, when providers encourage mothers to push while lying flat on their backs or in a semi-reclined position, knees widened apart, too early for too long, providing traction, it can further lodge baby compacted into a malposition, hinder fetal descent and cardinal movements. Which may push the mother's sacrum/coccyx bone backward, decrease the available space for the baby's shoulders to pass through, increasing the risk of shoulder dystocia in the inlet, mid-pelvis or outlet.
Outdated, mismanaged, or undertrained protocols by medical professionals in the context of shoulder dystocia can lead to increased risks and potential harm for both the mother and the baby.
It is recognized that many birth professionals are not familiar in assisting mobile maternal labor and birth positions which may disorient the perception of one's original training - of performing manual hands on assistance or expected management with a birthing woman in supine/lithomy position.
"As previously defined, shoulder impaction occurs in 0.2 to 3 percent of all births and represents an obstetric emergency. The overall incidence of shoulder impaction varies based on fetal weight, occurring in 0.3 to one percent of infants with a birth weight of 2500 to 4000 grams, and increasing to five to seven percent in fetuses weighing 4000 to 4500 grams. Over 50 percent of shoulder impactions occur in the normal birth weight fetus and are unanticipated. Few shoulder impactions can be anticipated and prevented, as most occur in the absence of risk factors.
Once a shoulder impaction occurs, even if all actions are appropriately taken, there is an increased risk of complications. These include third and fourth degree lacerations, post partum hemorrhage, and neonatal brachial plexus palsies. (Grobman 2011)"
Source: https://anmc.org/files/ShoulderDystocia.pdf The Alaska Native Tribal Health Consortium and Southcentral Foundation Shoulder Impaction a.k.a. Fetal Expulsion Disorder or Shoulder Dystocia
Birth professionals must then echo the question, what are the contributing root causes of these rising statistics, as it becomes evident that the standard risk factors alone do not account for the main cause. This realization prompts a critical examination of current practices, highlighting the urgent need for a comprehensive shift towards updated protocols that prioritizes optimal maternal positions that accommodate fetal cardinal navigation, informed decision-making and a new understanding of the multifaceted dynamics involved in childbirth physiology from all angles.
Some of the contributions and consequences of such situations include:
Delayed Response: If medical professionals are not adequately trained to recognize and respond to shoulder each variations of dystocia promptly, there can be a delay in implementing appropriate interventions. This delay can increase the risk of fetal compromise and maternal injuries.
Ineffective Maneuvers: Outdated or incorrect maneuvers used to manage shoulder dystocia can exacerbate the situation rather than alleviate it. Inappropriate techniques might increase pressure on the baby & mother, leading to potential injuries and complications.
Excessive Force: Improperly trained professionals might apply excessive force during maneuvers to free the baby's shoulders, resulting in maternal/fetal tears, injuries, or fractures.
Lack of Updated protocols: Outdated or inadequate education among medical professionals about current best practices for preventing & managing shoulder dystocia can result in limited awareness of effective techniques and maneuvers, hindering the implementation of necessary up to date protocols. Without access to updated protocols, medical professionals might resort to using techniques that have been proven to be less effective or even harmful in managing shoulder dystocia.
Increased Trauma: The application of outdated techniques can increase the physical and emotional trauma experienced by both the mother and the baby.
Prolonged Labor: Inefficient management of shoulder dystocia can lead to prolonged labor, causing maternal exhaustion and increasing the risk of maternal and fetal complications.
Risk of Litigation: In cases where outdated or mismanaged protocols result in injuries or complications, medical professionals and institutions might face legal consequences.
Patient Trust and Satisfaction: Experiencing a mismanaged or traumatic shoulder dystocia situation can erode patient trust and satisfaction with the healthcare provider and the overall childbirth experience.
Pathological recommendations and analysis
Shoulder Dystocia. RCOG Guideline No. 42, 2nd Edition March 2012. Royal College of Obstetricians and Gynaecologists
The HELPERR mnemonic
H Call for help
E Evaluate for episiotomy
L Legs (the McRoberts’ manoeuvre)
P Suprapubic pressure
E Enter manoeuvres (internal rotation)
R Remove the posterior arm
R Roll the patient
If the maneuvers described in the HELPERR mnemonic are unsuccessful after several attempts, the following techniques have been described as “last resort”:
Deliberate clavicle or humerus fracture Direct upward pressure on the midportion of the fetal clavicle will result in fracture and reduce the shoulder-to-shoulder distance. Traction across the humerus directly may fracture the humerus and may allow for posterior arm manipulation and facilitate resolution of shoulder impaction.
Muscle Relaxation Musculoskeletal or uterine relaxation can be induced with halothane or other general anesthetic. Alternatively, sublingual nitroglycerin may be used for uterine relaxation
“Heroic” Measures
If the maneuvers described above are also unsuccessful after several attempts, the following techniques have been described for cases of catastrophic shoulder impaction or FED
Overview in Analysis:
"Shoulder dystocia is an obstetric emergency with severe complications. Our objective was to evaluate the major pitfalls in the diagnostics of shoulder dystocia, diagnostic descriptions documented in medical records, use of obstetric maneuvers, and their correlations to Erb’s and Klumpke’s palsy and the use of ICD-10 code 066.0.
The pitfalls in the diagnostic included suboptimal following of guidelines for making the diagnosis of shoulder dystocia, subjective interpretation of diagnostic criteria, and inexact or inadequate documentation in medical records. The diagnostic descriptions in medical record were highly inconsistent. The use of obstetric maneuvers was suboptimal among shoulder dystocia cases (57.5%). Overall, the use of obstetric maneuvers increased during the study period (from 25.7 to 97.0%, p < 0.001), which was associated with decreasing rate of Erb’s palsy and increasing use of ICD-10 code O66.0.
Conclusion
There are diagnostic pitfalls, which could be addressed by education regarding shoulder dystocia guidelines, by improved use obstetric maneuvers, and more precise documentation. The increased use of obstetric maneuvers was associated with lower rates of Erb’s palsy and improved coding of shoulder dystocia.
Source: Heinonen, K., Saisto, T., Gissler, M. et al. Pitfalls in the diagnostics of shoulder dystocia: an analysis based on the scrutiny of 2274 deliveries. Arch Gynecol Obstet (2023). https://doi.org/10.1007/s00404-023-07022-8
Australian Hospital Guidelines - https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/shoulder-dystocia-guideline_280720.pdf
Shoulder Dystocia - Davis DD, Roshan A, Canela CD, et al. Shoulder Dystocia. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470427/
Promoting Optimal Birth Practices:
To minimize the risk of shoulder dystocia, it is crucial for healthcare providers to adopt birth practices that encourage optimal fetal positioning, pelvic mobility/space and facilitate fetal cardinal movements.
Here are some recommendations:
Functional Physiological birth system: (see below)
Upright or gravity-assisted positions: Encourage mothers to follow their intuition, adopt upright positions during labor and delivery, such as kneeling on all fours, standing, squatting, laying on her side keeping pelvic mobilization or using a birthing stool. These positions open the pelvis, allowing the baby to descend more easily.
Hands-and-knees position: Suggest the hands-and-knees position in both early/active labor-transition-pushing, also known as the all-fours position. This position helps to align the baby's shoulders with the mother's pelvis as they rotate through the widest diameters at each phase of labor, reducing the likelihood of shoulder dystocia.
Side-lying position: Encourage mothers to lie on their sides during labor and delivery. This position allows the pelvis to open naturally and reduces pressure on the coccyx/sitz bones.
Hip Extension and Hip Flexion: Hip Extensions are movements where there is contranutation/nutation of the iliac which is modifying the opening of the pelvis & Hip flexion causes iliac nutation and the degree of iliac nutation would be dependent on the degree of flexion
Asymmetry of the femur: Both hip extension and flexion concurrently;Different degree of flexion from one leg to the other leg. These movements causes both contranutation and nutation of the iliac and sacrum at the same time, hence modifying the opening of the pelvis both in the inlet pelvis on one side, and outlet pelvis on the other side.
Delayed/Intuitive pushing: Recommend delaying pushing until the mother feels the natural urge to push. Full dilation does not equal time to push. This approach allows the baby to descend further into the birth canal & complete their fetal cardinal movements, optimizing the chances of a smooth delivery.
Individualized care: Emphasize the importance of individualized care, taking into account each woman's unique circumstances, body structure, and preferences. Tailor the labor and delivery plan accordingly to promote optimal fetal positioning and movement.
While shoulder dystocia can occur due to a variety of factors, it is crucial to recognize the potential role of provider; encouraging outdated protocols and positioning during labor and delivery. Encouraging mothers to labor and push in positions that close the outlet and compact the coccyx bone may impede the completion of fetal cardinal movements, increasing the risk of shoulder dystocia. By promoting optimal birth practices that prioritize fetal positioning and movement, healthcare providers can help reduce the likelihood of shoulder dystocia and support safer and more positive birth experiences for both mother and baby.
It's important to address these issues by prioritizing up-to-date training and continuing education for healthcare professionals involved in childbirth. Proper training ensures that medical teams are well-prepared to handle shoulder dystocia scenarios effectively and with the best interests of both the mother and the baby in mind. Staying informed about current guidelines, protocols, and evidence-based practices is essential to ensure the safety and well-being of both patients and healthcare providers.
Outdated Protocols & Provider influence
"In about 500 births the only true dystocia I've handled was on an average size baby. Her first pregnancy I did a vaginal exam at 36 weeks and I could definitely feel her sacral promontory. We ended up transferring for elevated FHT's in early labor and I talked to the CNM about the pelvimitry and my concerns and she said, "Well, let's wait and see what happens with pushing." She efficiently pushed out a 6 1/2 pound baby. Next baby at home I could tell she was complete for a long time - like an hour or two, and I finally said, why don't you play around with pushing? Bad idea. We did some rebozo on her because baby was posterior and then she had the worst dystocia. I broke the baby's arm getting her out. Everyone was ok, but big lesson in not rushing pushing. Second baby was just over 7 pounds." - Anonymous Midwife
Shared in a private peer review group
The Medical Community seeks change
The medical community is undergoing a transformative phase, driven by the rising incidence of shoulder dystocia. Providers, collectively contributing to the challenge, are now turning to one another for solutions. However, the answers might be inherently embedded in the intricacies of a perfect physiological design. By allowing the intuitive interplay between the maternal body and the baby's rotation, and with proper training to discern genuine emergencies and dystocia variations, we can pave the way for a more effective and intuitive approach to childbirth.
Shoulder Dystocia, while familiar to healthcare professionals, has sparked a paradigm shift in perception. In an era of seeking solutions, a growing realization has emerged that perhaps the key isn't a forceful approach which further compacts the pelvis and fetus rotation followed by the often failed attempt at manual internal rotation, but in reshaping the role of mothers in fostering optimal fetal navigation through maternal mobile pelvic maneuvers.
The medical community is actively engaged in unraveling the complexities of shoulder dystocia, from obstetricians to midwives, each seeking to refine their approach.
A poignant reflection from an experienced practitioner echoes the prevailing sentiment. A traumatic experience involving the failure of traditional maneuvers sparked their own cascade of introspection. The practitioner questioned the routine practice of attempting posterior arm delivery, and the response of "that's not what we are taught" hit home. The truth resonated - a critical gap in understanding existed.
Indeed, a comprehensive approach to addressing shoulder dystocia must encompass not only understanding the provider's role in its occurrence but also recognizing the nuances within variations of shoulder dystocia and formulating distinct maneuvers for each scenario. Addressing these foundational elements is imperative before embarking on the development of updated protocols.
Changing Practice in Shoulder Dystocia: A Midwife’s Journey
"I witnessed a severe shoulder dystocia where the failure of the McRoberts, suprapubic pressure, internal rotational maneuvers and then an attempt at delivery of the posterior arm resulted in a complete fracture of the humerus. The baby was born by literally being ‘dragged’ out by the broken arm and required full resuscitation. Following this traumatic experience, I spent many hours reflecting on the events of that birth. I thought about the attempt at delivery of the posterior arm and the shock I felt when I heard the humerus fracture. The midwife who eventually delivered the baby explained the difficulty she had in trying to locate the fetal elbow because both fetal shoulders had remained above the pelvic brim. In trying to locate the elbow she only managed to grasp the upper arm and the subsequent traction against the arm had caused the fracture. The traction had caused some movement in the shoulder and so she continued to pull on the damaged arm until the shoulder eventually descended below the pelvic brim and she was able to pull the baby through the pelvis.
I asked her why she didn’t grasp the fetal shoulder and use that to pull the baby down (my thought had been that if any child was trapped anywhere the natural reaction is to secure the child under their armpits to attempt to pull them free). Her response was ‘that’s not what we are taught’. That was fair comment – it was not what we were taught. I began to question what I would do if I was in the same situation again. It was evident that the maneuvers we had been taught in our emergency skills days had failed in this situation and I realized the enormity of the practice problem we were facing."
1st September 2020 by All4Maternity.Posted in " Midwifery Practice, Practice Skills, Practising Midwives, TPM Articles, TPM Journal "
Published in The Practicing Midwife Volume 23 Issue 8 September 2020 https://doi.org/10.55975/EWWZ2758 "I experienced shoulder dystocia for the third time during my first unassisted free birth. The captains position is what I naturally moved my body into when I felt my baby “stuck”. I had already experienced shoulder dystocia two other times during the hospital birth of my second and third babies so when I felt my uncontrollable pushes become non productive, my body just adjusted without thought to put my leg up. The next surge brought my baby’s head down to crown, within seconds that ring of fire burned through me as my baby’s head was birthed, then the shoulder and whoosh!! Sweet relief as I lifted my sweet Roman Leonidas Maxwell into my arms at 8lbs 7 oz.
So much healing happened with his birth! It was nothing like the trauma I experienced with my second baby. I had an epidural so of course my midwife and nurses had me on my back with my legs up to my chest. I had zero feeling, I was completely unable to move (I now know how closed up my coccyx was). The nurses were pushing on my belly while my midwife reached inside me to pull out my baby and in doing so she tore her brachial plexus. My baby girl came into this world bruised up with a nearly paralyzed arm due to the negligence. They told me she was “too big” at 9lbs 12oz. Thank Yahuah I felt my 3rd baby get stuck even with the epidural because I was able to just shift my bottom to open up my pelvis and my baby was safely placed on my chest He was 9lbs 6oz. My 7th baby was freebirthed at 10 pounds with no shoulder dystocia! Position and mindset is everything in birth, we were made for this."
-Anonymous Wombsister
The traction maneuver, still highly recommended among medical professionals despite its track record, has faced a surge in legal actions due to resulting injuries. This raises questions about its relevance in contemporary practice prior to educating on all variations of SD, with indications that it might be gradually phased out as the primary approach for both preventing and resolving shoulder dystocia when it may contribute to further compaction or injury.
Shoulder dystocia: incidence, mechanisms, and management strategies
This comprehensive analysis of shoulder dystocia and its mechanical nature sheds light on the challenges faced by healthcare providers when diagnosing and defining this complication, as well as the importance of avoiding unnecessary medical interventions that could contribute to iatrogenic shoulder dystocia.
Iatrogenic Shoulder Dystocia: The piece cautions against exerting downward traction on the baby's head with the belief that the shoulders should immediately follow. Doing so may hinder the natural rotation of the shoulders at the pelvic inlet and potentially lead to iatrogenic shoulder dystocia (a complication caused by medical intervention).
Natural Mechanism of Shoulder Dystocia: In a typical vaginal delivery, the baby's head emerges first, followed by the shoulders. The shoulders usually align themselves in the anteroposterior diameter, which facilitates their passage through the maternal pelvis. However, in some cases, the shoulders may not immediately follow the head due to their position or the size of the baby.
The Risks of Downward Traction: The instinctive response during delivery when the shoulders don't follow immediately after the head is to apply downward traction on the baby's head. This is often done with the belief that this action will expedite the delivery of the shoulders. However, as the article highlights, this well-intentioned intervention can have unintended consequences.
Hindering Natural Rotation: Exerting downward traction can interfere with the natural rotation of the shoulders. The shoulders are compressible, and they should ideally be pushed forward toward the fetal chest to facilitate their passage through the maternal pelvis. If downward traction is applied prematurely, it may hinder this rotation, making it difficult for the shoulders to traverse the pelvic inlet.
Diagnosis Challenges: Shoulder dystocia isn't always straightforward to diagnose. It can present with a variety of clinical scenarios, making it a subjective diagnosis in many cases. This subjectivity poses a challenge for healthcare providers who must quickly and accurately identify shoulder dystocia during labor to take appropriate action.
Differing Definitions: highlighted are the discrepancies in defining shoulder dystocia. The lack of a universally accepted definition further complicates the diagnosis and recording of this complication. Various obstetric organizations may use distinct criteria for diagnosing shoulder dystocia, leading to differences in reported incidence rates.
Preferred Definition: The author favors a minority definition, where shoulder dystocia is defined as the failure of the mother to deliver the baby's shoulders with her own effort during the next contraction after the head's delivery.
Menticoglou S. Shoulder dystocia: incidence, mechanisms, and management strategies. Int J Womens Health. 2018 Nov 9;10:723-732. doi: 10.2147/IJWH.S175088. PMID: 30519118; PMCID: PMC6233701.
"Police are now investigating after a lawsuit alleging a baby was decapitated during delivery on July 9 2023 was filed in Clayton County against Southern Regional Medical Center and others
According to the complaint, 20-year-old Jessica Ross's water broke at 10 a.m. July 9 and she went to the emergency department at Prime Healthcare Service, Inc. d/b/a Southern Regional Medical Center in Riverdale.
At approximately 8:40 p.m., Ross was fully dilated and instructed to begin pushing. The complaint says the baby stopped descending due to shoulder dystocia while being delivered vaginally and Dr. Tracey St. Julian, M.D., reportedly attempted to deliver the baby vaginally using different methods, including applying traction to the baby's head.
After not being able to deliver the baby, Dr. St. Julian reportedly decided to perform a STAT Cesarean section at approximately 11:49 p.m. The baby's body and legs were then delivered at 12:11 a.m. and the baby's head was delivered vaginally.
The lawsuit claims that Dr. St. Julian did not tell Ross and her family about the decapitation when she spoke to them at approximately 5 a.m. July 10. The lawsuit also claims that the hospital discouraged Ross and the baby's father, Treveon Taylor Sr., from seeking an autopsy, saying a free autopsy was not an option for them under the circumstances. Instead, they reportedly encouraged the couple to have their son cremated instead of being sent to a funeral home.
When, Ross and Taylor demanded to see and hold their child, the baby was reportedly tightly wrapped in a blanket with his head "propped on top of his body" to conceal the fact that he was decapitated.
The family was ultimately told about the decapitation by the funeral home, according to the family's lawyer.
The lawsuit alleges Dr. St. Julian failed to practice according to medical standards when she "grossly negligently applied excessive traction on Treveon Isiah Taylor Jr.'s head and neck and grossly negligently failed to do a Cesarean section in a timely and proper manner, resulting in Treveon Isaiah Taylor Jr.'s decapitation and death."
The lawsuit also says Premier Womens' OB/GYN, LLC, is "liable for the grossly negligent acts and omissions of its employee and/or agent Tracey St. Julian, M.D., who cared for Ms. Jessica Ross and Treveon Isaiah Taylor, Jr. on or about July 9, 2023."
Additionally, several nurses are also being accused of gross negligence because they reportedly did not follow proper procedures once it was determined that a shoulder dystocia had occurred. According to the complaint, the nurses "owed an independent duty" to the Ross and her baby."
Police investigating, lawsuit filed after baby allegedly decapitated during delivery at metro Atlanta hospital | By Joyce Lupiani and Aungelique Proctor | Published August 9, 2023 | Clayton County | FOX 5 Atlanta https://www.fox5atlanta.com/news/lawsuit-filed-after-baby-allegedly-decapitated-during-delivery-at-metro-atlanta-hospital
This article below delves into the complexities of handling various shoulder dystocia variations, raising concerns about the absence of clear definitions, accurate diagnosis, effective resolution, and comprehensive documentation. The initial use of standard protocols, particularly the McRoberts’ maneuver, without proper differentiation of dystocia variations, can contribute to complications and further compaction through downward flexion and coached pushing.
Referencing the mentioned article, it is evident that expert guidelines often advocate the McRoberts’ maneuver, sometimes coupled with suprapubic pressure, as the initial approach to managing shoulder dystocia. However, this approach is questioned due to reported success rates of around 50% and a noticeable 10% incidence of brachial plexus injury associated with these maneuvers alone.
In many cases, multiple traction efforts are made on the baby's head during the diagnosis and attempted resolution of shoulder dystocia. While the McRoberts’ position itself is considered advantageous, its associated traction maneuvers can potentially lead to unintended complications.
The article also highlights the importance of differentiating between maneuvers that cause lateral traction on the brachial plexus and those that do not. Many injuries may stem from initial downward traction used for diagnosis or attempts during McRoberts’/suprapubic maneuvers.
The discussion underscores the need to avoid cutting any nuchal cord before delivery in cases of shoulder dystocia. Specific maneuvers involving assessing the position of the posterior shoulder and employing rotational or arm extraction techniques are discussed as potential steps to manage shoulder dystocia once diagnosed. The study raises important questions about the limitations and potential risks associated with the current approach to managing shoulder dystocia.
"The guidelines of the expert bodies (the American,6 the British,7 and the French19) all endorse the McRoberts’ maneuver with or without suprapubic pressure as the first-line treatment for the management of shoulder dystocia. I disagree. The reported success rates with these maneuvers as first-line measures is about 50%, with higher success rates generally in the reports with the highest incidences of shoulder dystocia.
Who can argue with this? The problem is that when one looks at reports20–23 of brachial plexus injury when the only maneuvers that have been used are the McRoberts’ maneuver, with or without suprapubic pressure, there is about a 10% incidence of brachial plexus injury.
The fact is that in the usual case of shoulder dystocia there have often been at least three traction efforts on the baby’s head, namely, the first downward traction used to diagnose shoulder dystocia and then a second downward traction attempt with the McRoberts’ maneuver, and a third traction attempt with the suprapubic pressure maneuvers.
The defence of using the McRoberts’ maneuver and suprapubic pressure as first-line treatment is that they are easy to perform and that they often resolve the shoulder dystocia. The further defence is that when comparison is made with the incidence of brachial plexus injury when the other standard maneuvers are used, such as rotation of the shoulders or delivery of the posterior or anterior arm, the rate of brachial plexus injury seems to be the same.
What is not emphasized, however, is that recourse to the other standard maneuvers is almost invariably made after there have been failed attempts with McRoberts’ maneuver and/or suprapubic pressure. As rotation maneuvers and direct arm extraction maneuvers do not cause lateral traction on the brachial plexus, most such injuries are almost certainly a consequence of the initial downward traction used to diagnose shoulder dystocia or to the traction attempts during the McRoberts’/suprapubic combination or to upward traction on the fetal head to try to free the posterior shoulder. McRoberts’ position is good; McRoberts’ maneuver, if that involves traction, is bad.
A final consideration: it is imperative that one avoid cutting any nuchal cord before delivery. If shoulder dystocia occurs it is a disaster.
Specific maneuvers
So the diagnosis of shoulder dystocia has been made by the inability of the mother to push the shoulders out by her own efforts and even after the McRoberts’ position has been employed.
What is the next step? The next step is to put one’s dominant hand into the posterior part of the pelvis and determine if the posterior shoulder is in the sacral concavity or not.
Almost always, the posterior shoulder has gotten past the sacral promontory and is present somewhere along the curve of the sacrum. This will virtually always be resolvable with the standard obstetrical maneuvers. There are two standard approaches, the rotational maneuvers and the arm extraction maneuvers."
Menticoglou S. Shoulder dystocia: incidence, mechanisms, and management strategies. Int J Womens Health. 2018 Nov 9;10:723-732. doi: 10.2147/IJWH.S175088. PMID: 30519118; PMCID: PMC6233701.
All-fours maneuver
"In 1976, Ina May Gaskin, a midwife, described a maneuver for the resolution of shoulder dystocia that involves placing the gravid mother on her hands and knees. Bruner (1998) used this procedure in 82 deliveries complicated by shoulder dystocia and was able to resolve the dystocia in 68 cases (82%) with this maneuver alone. The average time needed to move the mother into this position and to complete delivery was reported to be 2-3 minutes. Unfortunately, there was no detailed description of fetal and maternal outcome in this report. Also, reports about this procedure have generally been in the midwifery literature, involving a patient population less likely to have epidural anesthesia and thus more likely to be fully mobile.
It may be that the "all-fours maneuver" is merely another means of changing the angle of the symphysis in relation to the stuck shoulder, akin to McRoberts maneuver. Since the all-fours maneuver involves a gravid woman at the end of her pregnancy, exhausted by a long labor, often with an epidural in place, being moved quickly out of her delivery position onto all fours on her bed or on the floor, the practicality of this maneuver for a general obstetrical population is open to question. Unless more data is presented as to its efficacy and utility, it cannot be considered a standard procedure for the resolution of shoulder dystocia.
Are any particular maneuvers better than the shoulder dystocia resolution maneuvers?
This is not at all clear. There have been multiple reports by different authors claiming various degrees of success with each of the shoulder dystocia resolution maneuvers.
Leung in 2011 evaluated delivery methods in 205 cases of shoulder dystocia. He found that following the failure of McRoberts maneuver the subsequent application of rotational methods or of posterior arm delivery has similarly high rates of success although the former may be associated with less fetal injury. The rate of either brachial plexus injury or humoral fracture with rotational methods was 4.4% vs. 21% with delivery of the posterior arm. Leung et al suggest that delivery of the posterior arm is less safe than rotational methods.
Also, Leung’s success rate with McRobert’s maneuver alone in his largely Chinese patient population was only 25% as compared to multiple American studies showing the success rate with this maneuver to be in the 40% range.
On the other hand, Hoffman (2011) reviewed 132,098 deliveries in which there were 2018 shoulder dystocias for a rate of 1.5%. One hundred one of these--5.2%--resulted in a neonatal injury. Delivery of the posterior shoulder was associated with the highest rate of successful delivery compared to all other maneuvers with no difference in the rates of damage to the newborn. Hoffman recommends that the clinician move to delivery of the posterior shoulder if McRoberts maneuver and suprapubic pressure prove unsuccessful in the management of shoulder dystocia. The need for additional maneuvers was associated with higher rates of neonatal injury.
Finally, Spain (2015), in a study of 231 women who experienced a shoulder dystocia, found that individual maneuvers were not associated with composite morbidity, neonatal injury, or neonatal depression after adjusting for parity and duration of shoulder dystocia. His conclusion:
There was no association between shoulder dystocia maneuvers and neonatal morbidity after adjusting for duration, a surrogate for severity. Our results demonstrate that the clinician should utilize the maneuver most likely to result insuccessful delivery.
So what can be said about the efficacy of the various shoulder dystocia resolution maneuvers?
1. The various maneuvers have not been subjected to a randomized trial 2. No maneuver has been clearly shown to be superior to any other in terms of successfully resolving a shoulder dystocia or reducing the rate of newborn injury.
What are some of the recommended protocols for resolving shoulder dystocia?
Many authors have proposed various protocols of prescribed maneuvers for the resolution of shoulder dystocia. Most are similar with only minor variations.
When a shoulder dystocia is recognized, it is generally agreed that McRoberts maneuver and suprapubic pressure should be implemented rapidly and simultaneously. These by themselves will resolve more than half of all shoulder dystocias. If the shoulder dystocia persists, other maneuvers can be performed in any order. These include the Wood's screw or Rubins maneuver in either the clockwise or counter clockwise direction, attempting to deliver the posterior arm, and, in extremis, consideration of such techniques as the Zavanelli maneuver or symphysiotomy.
ACOG, in its bulletin on shoulder dystocia (2002, reaffirmed 2015), proposed the following sequence of maneuvers for reducing a shoulder dystocia:
1) McRobert’s maneuver and suprapubic pressure 2) Episiotomy—controversial 3) Rotational maneuvers 4) Delivery of posterior arm
Harris in a 1984 paper recommended a similar protocol:
1) McRoberts maneuver. 2) Suprapubic pressure. 3) Large mediolateral episiotomy if above steps fail. 4) Wood's screw maneuver. 5) Attempt to free posterior arm.
Gherman (1998) discussed the protocol for managing shoulder dystocia utilized at that time at the University of Southern California:
McRoberts maneuver Suprapubic pressure Procto-episiotomy Wood's corkscrew maneuver Posterior arm extraction Zavanelli maneuver or symphysiotomy if all else fails
McFarland (1996) reported that the use of two maneuvers alone --McRoberts and suprapubic pressure -- resulted in the resolution of 58% of 276 cases of shoulder dystocia in his series. He found that the addition of the Wood's Screw maneuver and delivery of the posterior arm were sufficient to resolve the shoulder dystocia in all remaining cases. He also found that there was a direct correlation between the rate of brachial plexus injury and the number of maneuvers employed to resolve the shoulder dystocia. A second correlation he found was that as the fetal weight increased, the number of maneuvers required to resolve shoulder dystocias increased.
Sentilhes (2016) discussed the guidelines for shoulder dystocia resolution from the French College of Gynecologists and Obstetricians (CNGOF)
Ask for help Perform McRoberts maneuver with or without suprapubic pressure. Apply traction along the umbilical-coccygeal axis Do either reverse Woods corkscrew maneuver or deliver posterior arm Perform an episiotomy if one has not yet been performed one Repeat maneuvers Go to third line maneuvers.
Sentilhes adds two notes:
1. The available data do not allow us to conclude that any one of these maneuvers is superior to any other. 2. The performance of these obstetrical maneuvers for treating shoulder dystocia does not routinely require an episiotomy.
As has been shown, different authors recommend different combinations of maneuvers in attempting to resolve shoulder dystocias. But what every author emphasizes, and what the ACOG bulletin stresses, is that the most important aspect of resolving a shoulder dystocia is for the obstetrician to have a clear-cut, well thought-out sequence of maneuvers already in mind when a shoulder dystocia is encountered. The general consensus is that the best results in resolving shoulder dystocias are obtained when an obstetrician:
(1) Recognizes the shoulder dystocia
(2) Knows the different maneuvers involved in attempting to resolve shoulder dystocia
(3) Implements them in a carefully controlled, calm, and organized fashion.
2017 Dr. Henry Lerner https://www.shoulderdystociainfo.com/resolvedwithoutfetal.htm
Questions to ask:
Did a provider (Ob or Midwife) play a role in the shoulder dystocia that you & your baby experienced?
If you yourself are an OB or Midwife, have you potentially played a role in the root cause, resolution or mismanagment of a shoulder dystocia? Did the maternal position your were encouraged or influenced to push in, play a role in the shoulder dystocia you & your baby experienced? Is Maternal positioning hindering fetal navigation & playing a role in shoulder dystocia? Have you witnessed a shoulder dystocia that was potentially influenced by & then mismanaged the provider? Could it of been avoided?
Rethinking Shoulder Dystocia Prevention & Intervention:
Reversing the Sequence for Safer Outcomes
Shoulder dystocia, a challenging complication during childbirth, demands a strategic approach to ensure the safety of both mother and baby. By revisiting intervention strategies, the possibility of avoiding outdated maneuvers and improving outcomes can be explored. One such approach involves reversing the sequence by prioritizing the "last resort" technique of the all-fours position as the initial response.
Challenges with Outdated Maneuvers:
Outdated maneuvers, while once considered standard practice, may prove ineffective or even harmful in certain shoulder dystocia scenarios. Techniques like the McRoberts maneuver and suprapubic pressure might lead to unintended complications when applied without a comprehensive understanding of the specific case.
Obstetric Analysis & Guidelines:
The following statement from a medical center's guidelines serves as evidence that professionals may lack complete comprehensive education and training in understanding the standard dynamic mobility of maternal anatomy from various angles. This lack of comprehension undermines their grasp of how the "all fours" maternal position optimally creates space for fetal navigation, both preventing and resolving shoulder dystocia, when foregoing the standard bed-ridden positions which contribute to the root cause in variations of shoulder dystocia.
"R – Roll the Patient
The “all fours” or “Gaskin” maneuver is a safe, rapid and effective technique for the reduction of FEB. The patient must roll from the existing position to an all-fours position. The precise mechanism by which the Gaskin maneuver acts to relieve the FED is unknown.
The pelvic diameters increase when laboring women change from the dorsal recumbent position. Radiographic studies indicate that pelvic measurements are least favorable for delivery in the dorsal lithotomy position. By rotating to the all fours position, the true obstetrical conjugate increases by as much as 10 mm and the sagittal measurement of the pelvic outlet increases up
to 20 mm.
The fetal shoulder often dislodges during the act of turning from a supine to “all fours” position, indicating that this movement alone may be sufficient to allow enough pelvic change to dislodge the impaction. Additionally, once the position change is completed, gravitational forces may aid in disimpaction of the fetal shoulders.
The “all fours” maneuver may be difficult for a woman who is fatigued or restricted by IV‘s, fetal monitors, epidural anesthesia or Foley catheter. The patient will often need assistance to re-position, given these entrapments. This position may be disorienting to clinicians who are unfamiliar attending a delivery in this position"
Source: https://anmc.org/files/ShoulderDystocia.pdf The Alaska Native Tribal Health Consortium and Southcentral Foundation Shoulder Impaction a.k.a. Fetal Expulsion Disorder or Shoulder Dystocia | Pg: 8,9
When standard approaches fall short, the segment proposes resorting to internal maneuvers or the 'all-fours' position. This underscores the need for an adaptive approach that recognizes the limitations of conventional protocols and embraces alternative strategies to address the complexities of shoulder dystocia effectively.
"66.3.2 What measures should be undertaken if simple techniques fail?
Internal manoeuvres or ‘all-fours’ position should be used if the McRoberts’ manoeuvre and suprapubic pressure fail. If simple measures (the McRoberts’ manoeuvre and suprapubic pressure) fail, then there is a choice to be made between the all-fours position and internal manipulation."
RCOG Green-top Guideline No. 42 7 of 18 © Royal College of Obstetricians and Gynaecologists
The Case for All Fours as the First Resort:
Consider the merits of prioritizing the all-fours position, traditionally a "last resort" technique, as the primary response to shoulder dystocia. This approach offers several advantages:
Natural Realignment: The all-fours position encourages natural realignment of the baby's shoulders, utilizing gravity to ease the impaction.
Facilitates Hip Flexion: Being on all fours allows the birthing person to engage in natural hip flexion, where the thighs move toward the abdomen. This movement aids in presenting the baby's head in the smallest possible diameter, optimizing the descent through the birth canal.
Encourages Hip Extension: The position also supports hip extension, promoting the opening of the pelvic outlet as the baby progresses. This extension is vital for a smooth transition, decreasing the chances of shoulder impaction and contributing to the prevention of shoulder dystocia.
Dynamic Pelvic Alignment: The gravitational pull and dynamic nature of the all-fours stance create a scenario where the hips can easily alternate between flexion and extension. This dynamic pelvic alignment facilitates the necessary adjustments for the baby's optimal alignment with the maternal pelvis.
Pelvic Inlet: The all fours position encourages the baby's head to align with the brim of the pelvis. This alignment facilitates engagement and flexion of the baby's chin, promoting effective fetal cardinal movement through the pelvic inlet.
Mid Pelvis (Cavity): When in the all fours position, the mother's spine is elongated and her pelvis is in a more open angle. This can create more space within the mid pelvis, allowing the baby's shoulders to navigate through the greater sciatic notch and reducing the likelihood of impaction.
Pelvic Outlet: The hands-and-knees posture widens the pelvic outlet by tilting the sacrum outward, providing a more favorable angle for the baby's passage through the bony structures. This can facilitate the smooth delivery of the baby's head and shoulders without unnecessary resistance.
Optimal Fetal Positioning: All fours position encourages the baby to navigate the most optimal spacefor birth, reducing the likelihood of impaction.
Mobility and Flexibility: The mother's ability to move and adjust her position can aid in freeing the baby's shoulders and facilitate smoother progress.
Minimal Risk: Compared to other techniques as a first resort that may contribute to further compaction or injury, such as deliberate clavicle or humerus fracture, the all-fours position poses minimal risk to both mother and baby.
Embracing a New Paradigm:
By adopting the all-fours position as the first-line response to shoulder dystocia, mothers & healthcare providers can potentially avoid the challenges posed by outdated maneuvers. This shift requires a comprehensive training approach that equips medical professionals with the skills and confidence to implement assisting this maternal position effectively.
Balancing Individual Cases:
Of course, every case of shoulder dystocia is unique, and the choice of intervention must be based on careful assessment of variation & circumstance. While the all-fours position presents numerous benefits, it's crucial to adapt the approach to the specific scenario and consider other options as needed. As a mother who has undergone an epidural will need to be in a side lying position to replicate the *all fours* benefit, with a peanut ball between the legs, knees in, feet out.
Conclusion:
The realm of obstetrics is ever-evolving, and the management of shoulder dystocia should reflect this ongoing progress. By reconsidering the conventional sequence of interventions and elevating the all-fours position from a "last resort" to the first-line response, medical professionals can potentially enhance the safety and well-being of both mother and baby during childbirth. As healthcare practices evolve, embracing evidence-based physiological techniques that prioritize natural alignment and minimal risk becomes paramount in providing optimal care to expectant mothers.
the McRoberts Maneuver: A Paradox of Intention and Outcome in Shoulder Dystocia
In the complex landscape of managing shoulder dystocia during childbirth, the McRoberts maneuver has long been a widely employed technique. Intended to alleviate impaction by flexing the mother's thighs toward her abdomen, this maneuver has shown success in some cases. However, a critical examination reveals a paradox: while the intention is to create space, the actual outcome can inadvertently contribute to further complications by closing the pelvis and compacting the fetus.
Understanding the McRoberts Maneuver: The McRoberts maneuver involves flexing the mother's thighs toward her abdomen while applying suprapubic pressure, aiming to free the impacted shoulder. This technique capitalizes on the leverage of leg movement and the angle created between the mother's thighs and abdomen.
The Unintended Consequence: Despite the well-intentioned design, the McRoberts maneuver can paradoxically contribute to a worsening situation in certain cases. By lifting the legs and flexing the thighs upward, the pelvic outlet may inadvertently close, exerting pressure on the baby's shoulders and exacerbating the impaction.
Mechanism of Compaction: When the mother's legs are lifted into the McRoberts maneuver, the fetal head is pushed deeper into the pelvis while the shoulders remain stuck behind the pelvic bone. This mechanism can result in increased compression and impaction of the baby, making it more challenging to dislodge the shoulders.
The Need for Tailored Approaches: The complexity of shoulder dystocia calls for a multidimensional approach that takes into account the unique characteristics of each case. While the McRoberts maneuver has its place and has proven successful in some instances, its potential to inadvertently worsen impaction highlights the importance of understanding when and how to apply it effectively.
Balancing Action and Caution: Rather than relying solely on a universal technique, medical professionals should approach shoulder dystocia with a comprehensive toolkit of interventions. Each case demands careful evaluation, considering factors such as variation, pelvic size, root cause & best route for resolution.
Conclusion: The McRoberts maneuver, though a widely practiced technique, brings to light the complex nature of managing shoulder dystocia. While it may offer relief in some scenarios, its potential to inadvertently contribute to compaction and impaction underscores the need for tailored approaches. As healthcare practices continue to evolve, a deeper understanding of each maneuver's implications can pave the way for safer and more effective interventions, ultimately ensuring the well-being of both mother and baby during childbirth.
The Need for Comprehensive Emergency Training:
Unfortunately, emergency training often focuses primarily on the symphysis pubis scenario, where the baby's anterior shoulder is impacted against the mother's pubic bone. While this is one variation of shoulder dystocia, it does not encompass the full spectrum of possible scenarios. Ignoring the variations of shoulder dystocia in emergency training can lead to ineffective interventions and potential harm to both the baby and mother.
Comprehensive emergency training should include education on the different variations of shoulder dystocia, the appropriate maneuvers for each scenario, and the importance of individualized care based on the specific obstruction location. By understanding the nuances of shoulder dystocia and practicing a range of management techniques, healthcare providers can be better prepared to address this complication and minimize potential harm.
Shoulder dystocia can occur in various parts of the pelvis, including the brim, mid-pelvis (cavity), or the outlet. Unfortunately, variations of shoulder dystocia are often overlooked in emergency training, leading to ineffective interventions and potential harm to the baby or mother. It is crucial for healthcare providers to receive comprehensive emergency training that encompasses the full spectrum of shoulder dystocia scenarios.
The prevalent focus on the symphysis pubis scenario in emergency training can inadvertently neglect the diverse variations of shoulder dystocia. This omission limits healthcare providers' ability to address the complexity of cases involving different parts of the pelvis. Neglecting these variations can result in inappropriate interventions and potential harm.
By expanding our understanding and refining our skills, we can ensure safer and more effective management of shoulder dystocia, ultimately enhancing the well-being of both the baby and mother during childbirth.
What is Shoulder dystocia: A situation where the baby's shoulders become lodged in the brim, mid cavity or outlet of the mother's pelvis during labor & birth
Understanding the Variations of Shoulder Dystocia:
Shoulder dystocia can occur in various locations within the pelvis, and each location presents unique challenges that require specific prevention + interventions.
Shoulder dystocia presents a dynamic challenge during childbirth, with variations that demand precise maternal maneuvers for safe resolution. Before applying interventions like the Flexion, McRoberts maneuver or suprapubic pressure, understanding the specific variation of shoulder dystocia is paramount to avoid exacerbating compaction and potential damage.
Let's explore the Shoulder Dystocia Variations:
Brim Dystocia (Unitlateral & Bilateral):
Unilateral brim dystocia: One of the baby's shoulders become impacted on the anterior pelvic brim (pubic symphysis) & the other in the sacral curve.
Bilateral brim dystocia: Both of the baby's shoulders become impacted on the pelvic brim at the pubic symphysis & the sacral promontory.
Mid-Pelvis (Cavity) Dystocia: the baby's shoulders become wedged within the middle part of the maternal pelvis, between the obturator interus muscle & posterior sacroiliac ligaments, held up by the piriformis, sacrotuberis & sacrospinous ligaments.
Outlet Dystocia:
Anterior/Posterior: Outlet dystocia occurs when the baby's shoulders become lodged in the pelvic outlet at the Coccyx + Sacrococcygeal ligament, sacroiliac ligaments & pubic bone.
Transverse: Outletdystocia occurs when the baby's shoulders become lodged transverse in the pelvic outlet at the Ischium: between the Sitz bones (Ischial tuberosities), Sacroiliac ligaments & or Ischial spines.
The Functional Physiological Birth system: Pelvic biomechanics:
•7 fetal cardinal movements
Engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. These coordinated movements allow the baby to navigate the pelvis and facilitate a smoother birth.
•Stages of Labor and Birth:
Greater Abdomen: Aligning for engagment
Inlet: Station: -2 to -5 | Lateral fetal navigational rotation
Mid-pelvis: +1 to -1 | Diaganol fetal navigational rotation
Outlet: +2 to +5 | Posterior-Anterior fetal navigational rotation •Maternal Pelvic Mobility:
The pelvic girdle joints are the joints that connect the bones of the pelvis and allow for movement and support- Pubic Symphysis, Lumbosacral Joint, Sacroiliac Joints, Sacrococcygeal Joint
Pelvic Mobility sequences:
1. Pelvic transitions (*Creates alignment*): Anterior, posterior, Lateral, Circular, figure 8, Jiggle, Shake, sway 2. Pelvic Tilts (*Creates pelvic space*): Anterior, Posterior & Lateral pelvic tilts with Lumbar extension & flexion
3. Pelvic Rotations (*Optimizes inlet & outlet*): Hip extension/Hip Flexion, Asymmetry of Femur, External/Internal rotation
Maternal positions:
Maternal mobility forms the foundational basis for preserving an open and conducive pelvis for optimal fetal navigation. The extent of hip flexion or extension is a pivotal factor that directly influences the space accessible for the baby to engage in and successfully complete their essential fetal cardinal movements, crucial for the birthing process. These considerations hold priority, irrespective of the specific cervical dilation, stage or the timing of contractions.
All of these maternal positions can be modified & combined with pelvic mobility sequences
Hands & knees, Elbows & knees, side lying with a peanut ball, standing, sitting, squatting, lunging, hanging from birth sling/rope, forward leaning flexion, backward leaning extension, sitting or reclined with asymmetry & lateral pelvic tilts, using a birth ball, peanut ball or CUB to sit on or lean over
External Hand Placement: Greater pelvis/Inlet:
Tubercles - applying counter pressure with both palms pulling inlet open.
S4/S5 Median Sacral Crest - applying palm/mid finger pressure downward, opens the inlet enhancing opportunity for fetal engagement. Mid-pelvis:
Top of Sacrum - applying pressure with the palm/fingers towards the top of the sacrum, creates space & opens the outlet. Outlet:
Top of Iliac crest/ilium - Applying Fingers over iliac crest + palms against the ilium, pressing inward, opens the outlet.
Sitz Bones - applying counter pressure with the palms facing outwards, as the mother pushes back against the palms, opens the outlet.
Signs of shoulder dystocia: •Reverse traction of the head/head turtling in & out •Fetal Heart tones deceling
•Maternal discomfort or pain
•Delayed delivery of the baby's head or shoulders
•Lack of progression with contraction/pushing
Identifying & Resolving each Variation of Shoulder Dystocia:
Mothers Intuition & Advocacy:
Listen when a mother discloses that she feels compaction, that something is wrong or baby is stuck
Brim Dystocia (Unitlateral/Bilateral):
Unitlateral brim dystocia: While one of the baby's shoulders become impacted on the pelvic brim (pubic symphysis) & the other shoulder is in the sacral curve.
Identify:
Lack of progression of the head being born
No change with each next contraction | considerably following 3+ contractions
Reverse traction of head/head Turtling out & back in
Fetal heart tones deceling
Maternal discomfort or pain
Pelvic Mobility Sequence Maneuvers for Resolution:
✴Employ the Mother to follow her intuition if she is already adopting a favorable maternal position that promotes the pelvic mobility sequences
Favorable maternal positions:
All fours
Hands & Knees
Elbow & knees
Side lying
Standing
Kneeling
Reclined
Pelvic Mobility Sequence Maneuvers for Resolution:
✴Employ *Chosen maternal position above* combined with
#2 Pelvic Tilts (*Creates pelvic space*): Anterior, Posterior & Lateral pelvic tilts with Lumbar extension & flexion
#3 Pelvic Rotations (*Optimizes inlet & outlet*): Hip extension/Hip Flexion, Asymmetry of Femur, External/Internal rotation
To create space for dis-impaction, thus releasing the anterior shoulder.
✴Employ patience following each maternal movement to allow for the baby to align with their new found opportunity for navigation on the following contractions
Bilateral brim dystocia: the baby's shoulders become impacted at both the pelvic brim & the sacral promontory/posterior inlet. This occurs when the anterior shoulder becomes stuck on the symphysis pubis and the posterior shoulder becomes stuck on the sacral promontory.
Identify:
Lack of progression of the head being born
No change with each next contraction | considerably following 3+ contractions
Reverse traction of head/head Turtling out & back in
Fetal heart tones deceling
Maternal discomfort or pain
Favorable maternal positions:
All fours
Hands & Knees
Pelvic Mobility Sequence Maneuvers for Resolution:
✴Employ the *All Fours* maneuver combined with
#1 Pelvic transitions (*Creates alignment*): Anterior, posterior, Lateral, Circular, figure 8, Jiggle, Shake, sway
#2 Pelvic Tilts (*Creates pelvic space*): Anterior, Posterior & Lateral pelvic tilts with Lumbar extension & flexion
#3 Pelvic Rotations (*Optimizes inlet & outlet*): Hip extension/Hip Flexion, Asymmetry of Femur, External/Internal rotation
To create space for dis-impaction, thus releasing the anterior & posterior shoulders simultaneously.
✴Employ patience following each maternal movement to allow for the baby to align with their new found opportunity for navigation on the following contractions
Mid-Pelvis (Cavity) Dystocia:
Mid-pelvis or cavity dystocia refers to the situation where the baby's shoulders become wedged within the middle part of the maternal pelvis, between the obturator formen & greater sciatic notch, held up by the periformis, sacrotuberis & sacrospinous ligaments.
Identify:
Lack of progression of the head being born; after crowning
No change with each next contraction | considerably following 3+ contractions
Reverse traction of head/head Turtling out & back in
Fetal heart tones deceling
Maternal discomfort or pain
Favorable maternal positions:
All fours with lunge
Pelvic Mobility Sequence Maneuvers for Resolution:
✴Employ the *All Fours with lunge* maneuver combined with
#1 Pelvic transitions (*Creates alignment*): Anterior, posterior, Lateral, Circular, figure 8, Jiggle, Shake, sway
#2 Pelvic Tilts (*Creates pelvic space*): Anterior, Posterior & Lateral pelvic tilts with Lumbar extension & flexion
#3 Pelvic Rotations (*Optimizes inlet & outlet*): Hip extension/Hip Flexion, Asymmetry of Femur, External/Internal rotation
To create space for dis-impaction, thus releasing the anterior & posterior shoulders simultaneously.
✴Employ patience following each maternal movement to allow for the baby to align with their new found opportunity for navigation on the following contractions
Outlet Dystocia Anterior/Posterior & Transverse:
Anterior/Posterior: Outlet dystocia occurs when the baby's shoulders become lodged in the pelvic outlet at the coccyx & pubic bone.
Identify:
Lack of progression after the head is born; compaction
No change with each next contraction | considerably following 3+ contractions
Fetal compromise
Fetal heart tones deceling
Maternal discomfort or pain
Favorable maternal positions:
All fours with lunge
Pelvic Mobility Sequence Maneuvers for Resolution:
✴Employ the *All Fours with lunge* maneuver combined with
#2 Pelvic Tilts (*Creates pelvic space*): Anterior, Posterior & Lateral pelvic tilts with Lumbar extension & flexion
#3 Pelvic Rotations (*Optimizes inlet & outlet*): Hip extension/Hip Flexion, Asymmetry of Femur, External/Internal rotation
To create space for dis-impaction, thus releasing the anterior & posterior shoulders simultaneously.
✴Employ patience following each maternal movement to allow for the baby to align with their new found opportunity for navigation on the following contractions
Transverse: Outlet dystocia occurs when the baby's shoulders become lodged transverse in the pelvic outlet at each sitz bones (ischial tuberosities).
Identify:
Lack of progression after the head is born; compaction
No change with each next contraction | considerably following 3+ contractions
Fetal compromise/Fetal heart tones deceling
Maternal discomfort or pain
Favorable maternal positions:
All fours with lunge
Pelvic Mobility Sequence Maneuvers for Resolution:
✴Employ the *All Fours with lunge* maneuver combined with
#2 Pelvic Tilts (*Creates pelvic space*): Anterior, Posterior & Lateral pelvic tilts with Lumbar extension & flexion
#3 Pelvic Rotations (*Optimizes inlet & outlet*): Hip extension/Hip Flexion, Asymmetry of Femur, External/Internal rotation
To create space for dis-impaction, thus releasing the anterior & posterior shoulders simultaneously.
✴Employ patience following each maternal movement to allow for the baby to align with their new found opportunity for navigation on the following contractions
Identifying the variations of shoulder dystocia externally can be complex, and relying solely on flexion of the baby's head may not accurately diagnose the variation, potentially leading to further compaction. Instead, when any combination of shoulder dystocia markers is observed, prioritizing pelvic mobility sequences as the initial course of action is recommended.
Steps to prevent Shoulder Dystocia: Maternal Position & Mobility -Free the coccyx/sacrum of compression -Asymmetrical femur - Hip flexion and extension -Pelvic tilts/transitions Fetal Navigation -Prevent/Release compaction -Support maternal pelvis to accommodate fcm (fetal cardinal movement) -Allow space & time for fcm without forced pushing, coaching or traction Wait for rotation + restitution -Avoid Forced or Coached Pushing/Pulling -Avoid Purple pushing between and during contractions -Avoid Pushing before baby has fully rotated through the outlet
Explore Shoulder Dystocia Pelvic mobility Sequences: protocols & maneuvers
These pelvic mobility sequences are to be performed by the laboring mother herself as maternal maneuvers, they can be used in any order accordingly and can be accommodated with proper pelvic counter pressure support
Pelvic Mobility Sequence Maneuvers for Resolution:
Pelvic transitions (*Creates alignment*): Anterior, posterior, Lateral, Circular, figure 8, Jiggle, Shake, sway.
Pelvic Tilts (*Creates pelvic space*): Anterior, Posterior & Lateral pelvic tilts with Lumbar extension & flexion
Pelvic Rotations (*Optimizes inlet & outlet*): Hip extension/Hip Flexion, Asymmetry of Femur, External/Internal rotation
These movements cause both contranutation and nutation of the iliac and sacrum at the same time, modifying the opening of the pelvis in the inlet on one side and outlet on the other side to reduce the likelihood of compaction leading to prolonged shoulder dystocia or tearing
Shoulder dystocia prevention + prevailing requires promoting optimal pelvic mobility and positioning to create favorable space for fetal navigation during labor and delivery.
Let's explore these maneuvers in more detail:
Pelvic Mobility Sequence #1: Pelvic transitions (*Creates alignment*): Anterior, posterior, Lateral, Circular, figure 8, Jiggle, Shake, sway.
Can be performed whilst: Standing, sitting, squatting, leaned forward, on all fours
Anterior Transitions: Forward movements emphasizing the pelvic tilt toward the front.
Posterior Transitions: Backward movements focusing on the pelvic tilt toward the rear.
Lateral Transitions: Sideways movements involving a gentle shift of the pelvis to the left or right.
Circular Movements: Rotational motions, creating a circular pattern to promote flexibility and alignment.
Figure 8 Movements: Deliberate movements tracing the shape of a figure eight, engaging different pelvic muscles.
Jiggle Techniques: Gentle and rhythmic movements, producing a subtle jiggle to encourage pelvic alignment.
Shake Movements: Vibrational motions designed to release tension and encourage pelvic mobility.
Swaying Motions: Side-to-side rocking movements to promote a natural and relaxed alignment.
The described pelvic transitions and movements offer multifaceted benefits during labor. These techniques contribute to pain relief by fostering flexibility and alignment, potentially alleviating discomfort for the birthing mother. Simultaneously, they support optimal fetal navigation through the birth canal, influencing the baby's positioning and aiding in a smoother descent. Furthermore, these movements promote labor progression by encouraging rhythmic contractions and facilitating the baby's rotation. Beyond physical benefits, the techniques contribute to relaxation and tension release, enhancing the overall birthing experience. The emphasis on optimal pelvic alignment underscores the potential for reducing complications and supporting an efficient birthing position.
Pelvic Mobility Sequence #2: Pelvic Tilts (*Creates pelvic space*): Anterior, Posterior & Lateral pelvic tilts with Lumbar extension & flexion
Can be performed whilst: Standing, sitting, squatting, leaned forward, on all fours
Anterior Pelvic Tilt:
How to: Stand or sit comfortably. Instruct the person to tilt their pelvis forward by arching their lower back.
Posterior Pelvic Tilt:
How to: Similar to anterior tilt, stand or sit comfortably. Guide the person to tilt their pelvis backward by rounding their lower back.
Lateral Pelvic Tilt:
How to: Stand or sit with feet hip-width apart. Encourage the person to tilt their pelvis to the side, lifting one hip higher than the other.
Pelvic Tilts with Lumbar Extension:
How to: Instruct the person to stand with their feet shoulder-width apart. Encourage a gentle anterior pelvic tilt while also extending the lower back.
Pelvic Tilts with Lumbar Flexion:
How to: Similarly, guide the person to stand comfortably. Instruct them to perform a posterior pelvic tilt while flexing the lower back.
Anterior and posterior pelvic tilts with lumbar extension and flexion help to promote mobility in the pelvis and optimize the space available for the baby's shoulders to pass through during delivery. These movements also facilitate the engagement of the fetal head in the pelvis, reducing the risk of shoulder dystocia as baby navigates the space made available to them throughout labor.
Left & Right Lateral Pelvic tilt Benefits
Left Lateral Pelvic Tilt: Sitting with a left lateral pelvic tilt during labor involves positioning your body slightly tilted to the left side rather than sitting directly on your butt (compacting the sacrum & coccyx - minimizing pelvic outlet space). This can be achieved by simply leaning and elevating it slightly.
Benefits of left lateral pelvic tilt include:
Improved Blood Flow: This position can enhance blood circulation to the placenta and the baby, promoting optimal oxygen and nutrient supply.
Reduced Pressure on Vena Cava: By tilting to the left, pressure on the inferior vena cava (a major vein) is minimized, preventing reduced blood return to the heart and promoting better maternal circulation.
Enhanced Comfort: The left lateral tilt can relieve pressure on the lower back (sacrum) and pelvic floor area, potentially reducing discomfort during contractions.
Facilitated Baby Positioning: This posture encourages the baby to align with the most optimal space available, which may help in optimal positioning for birth.
Right Lateral Pelvic Tilt: Sitting with a right lateral pelvic tilt involves tilting your body slightly to the right side. Rather than sitting directly on your butt (compacting the sacrum & coccyx - minimizing pelvic outlet space).
Benefits of right lateral pelvic tilt include:
Pressure Relief: The right lateral tilt can alleviate pressure on the left side of the body, potentially reducing discomfort during labor.
Enhanced Comfort: This posture can provide relief to the lower back and pelvis, making contractions more manageable.
Promoted Fetal Positioning: This posture encourages the baby to align with the most optimal space available, which may help in optimal positioning for birth.
Both left and right lateral pelvic tilts offer advantages in terms of blood flow, pressure relief, and potential benefits for baby positioning & preventing or combating fetal compaction and shoulder dystocia. These positions can be rotated periodically to provide comfort and support during labor, promoting a more comfortable birthing experience.
Pelvic Mobility Sequence #3: Pelvic Rotations (*Optimizes inlet & outlet*): Hip extension/Hip Flexion, Asymmetry of Femur, External/Internal rotation
Can be performed whilst: Standing, sitting, side lying with a peanut ball, squatting, leaned forward, on all fours
Hip Extension:
How to:
Extend hips forward, one or both legs backward, emphasizing the stretch in the groin area.
Hip extensions causes iliac contranutation, where the inlet pelvis opens from the top of the iliac and the outlet pelvis closes at the iliac. This is very helpful in creating space for babies to enter the pelvis as it allows more room for flexion to occur, whether the baby is still in the greater pelvis, is moving towards inlet pelvis, or if baby is anterior or posterior.
Hip extensions can be incorporated into the birthing process when the laboring mother assumes various maternal positions conducive to smoother labor and delivery.
Maternal positions for facilitating hip extension as the baby navigates the brim:
Standing extension:
Standing while leaning her upper body forward into an extension, supported by a birth rope, a squat bar, partner/doula or against a wall.
Leaned back over a peanut ball:
Leaned back over the arch of the peanut ball, supporting the arch of her spine, the birthing mother can extend her pelvis
Extending in 'All Fours':
Tilting her pelvis forward, the mother moves from hands and knees, forward into an arch in her spine, groin touching the floor/bed. Extend legs out straight behind, similar to the cobra yoga pose
Side-Lying Position with Peanut Ball:
Adopting a side-lying position using a peanut ball or stirrups for support, with the spine in an arch and femur extension, often referred to as 'Flying Cowgirl' when using a peanut ball behind the mother, under her top leg. This can also be performed asymmetrically, modifying pelvic opening at the inlet & outlet.
Hip Flexion:
How to:
Bring one or both knees toward your chest, flexing the hip joint.
When there is iliac nutation, the inlet pelvis closes from the iliac crest and the mid to outlet pelvis opens at the base of the iliac. The Active Birth ‘all-four’s’ position is a commonly used position in flexion.
There are various degrees of hip flexion:
Less than 90 degrees;
90 degrees is the neutral position where legs are hip-width apart, hip-knees-ankles are in a right angle;
More than 90 degrees otherwise known as ‘extreme flexion’: This is when her knees are higher than her hips which causes the outlet pelvis to open and closes the inlet pelvis. Any position where her knees are higher than her hips should be avoided until her baby’s head is in the outlet pelvis and she is bearing down and/or pushing.
Initiating hip flexion induces iliac nutation, and the extent of iliac nutation is contingent upon the degree of flexion.
Maternal positions for facilitating hip flexion as the baby enters the midpelvic outlet include:
Standing with Support:
The mother stands, aided by a birth rope, squat bar, or support from her birth partner/doula, squatting at various degrees.
Sitting on a Birth Ball/Cub/Toilet:
Seated on a Birth Ball/Cub/Toilet, the mother can actively engage hip flexion, on tip toes, leaning forward for a higher degree of flexion, as the baby progresses through the midpelvic outlet.
Kneeling or 'All-Fours':
Adopting a kneeling or 'all-fours' position, the mother facilitates hip flexion, creating an optimal alignment for the baby's descent. Combine with a lunge for extreme flexion.
Side-Lying:
In a side-lying position with the peanut ball infront, under the top leg, the mother supports hip flexion, offering a comfortable and effective stance for the baby's movement through the midpelvic outlet.
Reclined:
Reclined back, the mother encourages hip flexion by lifting one of both legs up with internal rotation, a versatile option especially accompanied by asymmetry of the femur.
Asymmetry of the Femur:
How to:
- Sit/Recline with feet hip-width apart.
- Shift the weight onto one leg/sitz bone, allowing the other leg to extend and relax.
- Emphasize the asymmetry by creating a slight tilt in the pelvis.
- Combine with internal/external rotation.
Maternal positions for Facilitating asymmetry of the femur in different labor positions:
Sitting Positions:
Shift weight onto one sitz bone, allowing the opposite leg to extend.
Kneeling Positions:
Emphasize asymmetry by shifting weight to one side.
Lying Down Positions:
Emphasize asymmetry by tilting the pelvis by raising or lowering the upper leg.
Reclining Positions:
Lift or bend one leg and lean onto the opposing sitz bone to create an asymmetrical tilt.
Hands and Knees Positions:
Emphasize asymmetry by shifting weight from left to right while swaying or rocking.
Assisted Positions:
Create asymmetry by adjusting leg using a block to lift and place your knee or foot on.
External/Internal Rotation:
How to (External rotation) | Supporting Inlet navigation:
- Rotate one or both knees outward, emphasizing the external rotation of the hip joint.
How to (Internal rotation) | Supporting Outlet navigation:
- Rotate one or both knees inward, emphasizing internal rotation of the hip joint.
Maternal positions for Facilitating External/Interal Rotation
Sitting Positions:
Internal Rotation: rotate the knees inward
External Rotation: rotate the knees outward
Kneeling Positions:
Internal Rotation: Knees in, feet out
External Rotation: Knees out, feet in
Side lying Positions:
Internal Rotation: In side-lying, guide the upper leg inwards for internal rotation, support with a peanut ball and drop the knee down, foot up
External Rotation: Control the external rotation using a peanut ball between the legs to lift the knee up & drop the foot down
Reclining Positions:
Internal Rotation: Drop the knee inward
External Rotation: Extend the knee outward
Hands and Knees Positions:
Internal Rotation: Knees apart, feet together
External Rotation: Knees together, feet apart
Lunging Position:
Internal Rotation: Drop knee in, feet out
External Rotation: Drop knee out, feet in
Pushing Positions:
Internal Rotation: Encourage & Facilitate internal rotation if the baby is decending through the outlet - combine with asymmetry
External Rotation: Encourage & Facilitate external rotation if the baby is hung up on the brim/pubis - knees out, feet in - combine with hip extension
These maneuvers can reduce the risk of shoulder dystocia by promoting optimal fetal positioning.
Correct Hand Placement
Root causes of Shoulder Dystocia:
Lack of updated physiological birth training:
Misunderstanding of differentiating variation of dystocia: to determine proper protocol often leading to maternal and fetal injury. Outdated protocols often focus on a single scenario (e.g., symphysis pubis version) while overlooking the different variations that can occur at the pelvic brim, mid-pelvis, or outlet. This oversight can result in unnecessary interventions such as McRoberts Maneuver or Suprapubic Pressure (Rubin 1) & Internal maneuvers.
Potentially ineffective or interfering Medical Practices & maneuvers: which may contribute to the root cause & mistreatment of shoulder dystocia
Manual Induction/Active management of labor:
The controlled progression of labor: may inadvertently increase the risk of shoulder dystocia by accelerating the baby's descent before proper rotation or positioning can occur, limited positional freedom for maternal mobility by monitored progression, inadequate cervical ripening by lack of favorable environment & timing, leading to waterfall of intervention
Impact on Fetal Positioning: The use of manual induction or active management of labor can influence the baby's positioning during birth. Rapid labor progression may not provide enough time for the baby to naturally navigate the birth canal and assume the optimal position for passage through the pelvis. Inadequate rotation or malpositioning can increase the likelihood of shoulder dystocia.
Manual rupture of membranes
Manual rupture of membranes: is often performed to enhance the intensity and frequency of contractions, resulting in a more rapid labor progression. While this intervention can be beneficial in certain situations, it may shorten the time available for the baby to assume an optimal position and navigate the birth canal, potentially increasing the risk of shoulder dystocia.
Premature Descent: The release of amniotic fluid through manual rupture of membranes can cause the baby to descend into the pelvis earlier than expected. Premature descent without adequate time for rotation and proper alignment may lead to the baby's shoulders getting stuck during delivery, resulting in shoulder dystocia
Mal-Maternal positioning:
Compacted/immobile Maternal positioning: during active/transition/pushing causing Fetal Malpositioning-Compaction-Dystocia by reducing the available space, alignment and mobility to navigate the pelvic floor.
Certain maternal positions: can inadvertently close the pelvic inlet, cavity & outlet, reducing the space available for the baby to descend through the birth canal.
Supine/Reclined: is when a woman is positioned flat on her back (supine position) during labor and pushing | In a bed, in the tub, on the floor etc. This position can compress the sacrum and coccyx, narrowing the pelvic outlet and hindering the baby's passage. This restriction can impede the proper fetal navigation and cardinal movements required for a smooth birth. Optimal positioning and alignment that keep the pelvic outlet open, such as upright positions like hands & knees, squatting, lunging or side-lying positions that accommodate the same pelvic space for FCM (fetal cardinal movements), are recommended to promote a more favorable birth experience and reduce the risk of complications like shoulder dystocia.
Forced pushing
Compaction of Sacrum and Coccyx: When a woman is coached or forced to push before she feels the natural urge to do so or push with excessive force, it can lead to increased pressure and compression on the sacrum and coccyx. This compression can result in the narrowing of the pelvic outlet, limiting the space available for the baby to descend through the birth canal.
Restricted Fetal Navigation: The excessive pressure and compaction on the sacrum and coccyx can restrict the mobility and flexibility of the pelvic bones. This restriction hampers the baby's ability to navigate effectively through the birth canal, impeding their progress and making it challenging for them to find the optimal position for birth.
Impaired Cardinal Movements: Cardinal movements are vital for the baby's descent and rotation through the birth canal. Forced pushing can disrupt these cardinal movements by hindering the baby's ability to navigate and adjust their position as needed. This can interfere with the smooth progression of the birth process and potentially contribute to shoulder dystocia.
Active management of delivery/Traction
Increased Tension in the Birth Canal: The active management of delivery, often involving traction or pulling to expedite the birthing process, can inadvertently contribute to increased tension in the birth canal. This heightened tension, especially when applied during a critical moment such as the baby's shoulders navigating the pelvic outlet, may escalate the risk of shoulder dystocia by impeding the smooth descent of the baby.
Disruption of Natural Mechanisms: Traction during active management can disrupt the natural mechanisms of childbirth. The body's innate ability to facilitate the optimal passage of the baby through the birth canal may be compromised, potentially leading to a misalignment of the shoulders and an increased likelihood of shoulder dystocia.
Unintended Compression and Impaction: Traction, when applied forcefully or inappropriately, may inadvertently compress the baby's shoulders or cause them to become impacted in the pelvic oulet. This compression and impaction, combined with the unique dynamics of the birth canal, contribute to the root cause of shoulder dystocia, posing risks for both the birthing person and the baby.
Pushing for a prolonged period of time
Maternal & Fetal Exhaustion and Reduced Effectiveness: Prolonged pushing may result in maternal & fetal exhaustion, diminishing the effectiveness of contractions, fetal cardinal movements and pushing efforts. As the birthing mother becomes fatigued, the natural propulsive forces that assist the baby's descent may wane.
Malpositioning of the Fetal Shoulders: Extended pushing duration may result in the malpositioning of the fetal shoulders, increasing the likelihood of them getting stuck. The prolonged pressure and force applied during pushing can exacerbate this situation, contributing to the root cause of shoulder dystocia by impeding the smooth passage of the baby through the birth canal.
Fetal cardinal movement interference
Routine Interventions and Labor Management: The application of routine interventions, such as continuous electronic fetal monitoring, epidural anesthesia, and augmentation of labor with synthetic oxytocin, may influence fetal cardinal movements. These interventions can impact the natural progression of labor and potentially impede optimal fetal positioning & navigation, contributing to an increased risk of shoulder dystocia.
Supine Positioning during Labor: The common practice of having birthing mothers in a supine or lithotomy position for delivery can influence fetal cardinal movements. This positioning may restrict pelvic dimensions and hinder the baby's ability to navigate through the birth canal in a manner aligned with the cardinal movements, potentially contributing to complications like shoulder dystocia.
Routine Episiotomy: The routine use of episiotomy, although less common in modern obstetrics, has historically been associated with altered fetal cardinal movements. Episiotomies can affect the natural biomechanics of childbirth, potentially leading to challenges in the rotation and descent phases and contributing to an increased risk of shoulder dystocia.
Excessive Use of Forceps or Vacuum Extraction: The use of forceps or vacuum extraction during delivery, can impact fetal positioning. Excessive force or improper application of these instruments may contribute to fetal compaction, potentially complicating the normal cardinal movements and increasing the risk of shoulder dystocia.
Gestational Diabetes
Macrosomia Risk: Gestational diabetes is associated with an increased risk of macrosomia, where the baby grows larger than average. This larger fetal size can contribute to the root cause of shoulder dystocia, making the passage through the birth canal more challenging.
Excessive Fetal Growth: Elevated maternal blood glucose levels in gestational diabetes can lead to excessive fetal growth, a condition known as fetal macrosomia. The increased size of the baby can contribute to difficulties in navigating the birth canal, heightening the risk of shoulder dystocia during delivery.
Macrosomia
Increased Fetal Size: Macrosomia, characterized by a larger-than-average fetal size, is associated with the root cause of shoulder dystocia. The larger fetal dimensions can make the baby's passage through the birth canal more challenging, heightening the risk of the shoulders becoming impacted.
Higher Risk in Diabetic Pregnancies: Gestational diabetes, a condition often linked to macrosomia, increases the likelihood of shoulder dystocia. Elevated maternal blood glucose levels can contribute to the baby's overgrowth, exacerbating the root cause of shoulder dystocia during childbirth.
Limited Maternal Mobility: Continuous fetal monitoring can restrict maternal movement during labor. Limited mobility may impede the natural cardinal movements of the baby within the birth canal, potentially increasing the risk of shoulder dystocia.
Influence on Maternal Positioning: Fetal monitoring devices often require the birthing person to stay in specific positions, affecting maternal positioning. This restriction can interfere with the optimal alignment of the baby during descent, contributing to the higher risk of being restricted and potentially leading to shoulder dystocia.
Pendulous maternal abdomen
Altered Fetal Presentation: A pendulous maternal abdomen, often associated with conditions such as a pendulous uterus or excess abdominal tissue, can lead to an altered fetal presentation. The baby's positioning may be influenced by the pendulous abdomen, increasing the likelihood of an abnormal presentation and contributing to inlet dystocia.
Impaired Engagement: The presence of a pendulous abdomen can impact the engagement of the fetal head in the maternal pelvis. Impaired engagement may result in malposition for the baby's descent through the birth canal, potentially increasing the risk of dystocia.
Abdominal lift & tuck: tuck the pelvis & wrap hands or rebozo under the abdomen & lift for 5-10 seconds. The intentional lifting action helps release pressure on the baby's shoulders, allowing for improved rotation and descent through the birth canal.
Fetal compaction due to the above circumstances
Fetal compaction, influenced by certain circumstances within the mainstream medical system, refers to the compression or constriction of the baby's position within the birth canal, potentially hindering the natural cardinal movements. The above factors may contribute to fetal compaction and further exacerbate the risk and likelihood of shoulder dystocia
Factors associated with shoulder impaction (RCOG 2012, ACOG 2014)
Pre-labor
Previous shoulder impaction
Macrosomia
Diabetes mellitus
Maternal body mass index > 30 kg/m2
Induction of labor
Post term pregnancy
Intrapartum
Assisted or operative vaginal delivery
Fetal malposition
Oxytocin augmentation
Prolonged second stage of labor
Secondary arrest
Prolonged first stage of labor
RCOG Guideline No. 42, 2nd Edition March 2012. Royal College of
Obstetricians and Gynaecologists
Trauma to Fetus & Mother from Shoulder Dystocia The application of outdated techniques can increase the physical and emotional trauma experienced by both the mother and the baby.
Fetal manipulation techniques used to alleviate shoulder dystocia are indeed associated with an increased rate of bone fracture or brachial plexus injury, despite the mainstream lack of admittance; in peer review and analysis
Misunderstanding of differentiating variation of dystocia to determine proper protocol often leading to Mismanaged Dystocia protocols which can cause the following traumas:
•Mismanaged Dystocia protocols •Damaged fetal clavical nerve •Broken fetal arm •Compromised fetal Neurology •Damaged maternal pelvis/spine/hips •Maternal tear & hemorrhage due to forced delivery/episiotomy or placental delivery complication
During shoulder dystocia, several factors can contribute to fetal compromise:
Compression of the Umbilical Cord: The prolonged pressure on the baby's head and neck during shoulder dystocia can lead to compression of the umbilical cord. This compression can reduce the flow of oxygen and nutrients from the placenta to the baby.
Decreased Blood Flow: The pressure on the baby's head and neck can lead to decreased blood flow to the brain and other vital organs, which can result in oxygen deprivation.
Brachial Plexus Injury: While trying to dislodge the baby's shoulders, there's a risk of stretching or injuring the brachial plexus, a network of nerves that control the arm and hand muscles. This can lead to temporary or permanent nerve damage.
Fractures and Injuries: The baby's bones, particularly the collarbone (clavicle) and upper arm bone (humerus), can be at risk of fractures or injuries as they are manipulated during delivery.
Hypoxic-Ischemic Encephalopathy (HIE): In severe cases, prolonged oxygen deprivation can lead to hypoxic-ischemic encephalopathy, a brain injury caused by lack of oxygen and blood flow to the brain. This can result in cognitive, motor, and developmental disabilities. During shoulder dystocia, several factors can contribute to maternal compromise:
Perineal Tears: Forceful manipulation, episiotomies and pathophysiological maneuvers to address shoulder dystocia can result in perineal tears or lacerations.
Episiotomy Complications: If an episiotomy is performed to widen the vaginal opening, improper technique or excessive force can lead to complications such as deep tears or infections.
Vaginal Wall Trauma: The use of excessive force during maneuvers can cause tears in the vaginal walls.
Uterine Rupture: If outdated or inappropriate maneuvers are employed, there is a risk of uterine rupture, which can lead to severe bleeding and other complications.
Cervical Tears: Aggressive attempts to dislodge the baby's shoulders can result in tears or injuries to the cervix.
Pelvic Floor Injuries: The use of force or improper techniques can lead to strain or injury in the pelvic floor muscles and ligaments.
Pudendal Nerve Damage: Forceful maneuvers during shoulder dystocia can potentially damage the pudendal nerve, causing pain, numbness, or tingling.
Rectal Injuries: Excessive pressure and manipulation can lead to rectal injuries during shoulder dystocia management.
Postpartum Hemorrhage: Interventions to address shoulder dystocia can increase the risk of postpartum hemorrhage due to uterine atony or trauma.
Fractures or Dislocations: In rare cases, the use of forceful maneuvers can lead to maternal fractures or dislocations.
Emotional Trauma: Experiencing complications or injuries due to outdated or mismanaged protocols can lead to emotional trauma for the mother.
Prolonged Labor Effects: Ineffective management of shoulder dystocia can lead to prolonged labor, increasing the risk of maternal exhaustion and complications.
Infections: Poorly executed maneuvers or interventions can lead to infection at the site of tears, incisions, or injuries.
Damage to Other Organs: Aggressive maneuvers can potentially result in damage to adjacent organs such as the bladder or rectum.
Pain and Discomfort: Improperly performed maneuvers can cause increased pain and discomfort for the mother during recovery.
Questions to ask a provider before hiring them apart of your birth team: How many shoulder dystocias have you witnessed?
What do you feel are the contributing factors to the root causes of shoulder dystocia? What is your SD protocol, what meassures do you take to prevent or handle?
Can you share your experiences in handling or witnessing shoulder dystocia?
How many variations of shoulder dystocia exist?
Navigating Birthing Positions: Understanding the Birth Tub and Shoulder Dystocia Connection
In the realm of birthing options, the birth tub has emerged as a popular choice, offering a soothing haven with benefits like buoyancy, relaxation, and pain relief for many expectant individuals. However, as we explore the diverse landscape of birthing positions, it's crucial to shed light on the potential correlation between sitting reclined in a birth tub and the occurrence of shoulder dystocia, particularly when combined with manual hands-on assistance.
The Birth Tub Appeal:
The allure of a birth tub lies in its ability to create a serene environment for labor and delivery. The buoyancy of the water provides comfort, relaxation, and relief from the intensity of contractions. However, the specific positioning within the birth tub, particularly the reclined posture, warrants careful consideration due to its potential implications for shoulder dystocia.
Unpacking the Connection:
When a birthing person sits reclined in a birth tub, the sitz bones remain immobile as both legs are extended out, the coccyx bone takes on a posterior position, protruding into the birth canal. This backward tilt reduces the available space for the baby's shoulders to navigate during delivery, increasing the risk of shoulder dystocia. The compacted fetal position, coupled with the pressure on the coccyx bone, creates a scenario where the baby's shoulders may become compacted at the outlet.
Manual Hands-On Assistance - The Interference of Flexing the Baby's Head:
Adding a layer of complexity to this scenario is the potential for manual hands-on assistance, specifically the practice of feeling or flexing the baby's head. While aiming to facilitate the birthing process, this intervention, when applied while the baby is compacted at the coccyx and sitz bones, can inadvertently exacerbate the risk of shoulder dystocia. By flexing the fetal head, there's an increased chance of the baby's shoulders becoming wedged behind the pubic bone, intensifying the challenge of navigating through the constrained birth canal.
Furthermore, the combination of manual assistance and the reclined position may disrupt the delicate balance required for a smooth descent. Careful consideration and communication between healthcare providers and birthing mothers are paramount to ensuring that interventions, including hands-on assistance, align with the best interests of both the birthing mother and the baby.
Informed Decision-Making:
As we delve into the intricacies of birthing positions, it becomes clear that informed decision-making is paramount. Healthcare providers and expectant individuals alike should engage in open conversations about alternative positions, such as asymmetry or hands and knees, that not only prioritize optimal fetal positioning but also work towards minimizing the likelihood of encountering shoulder dystocia.
Conclusion:
While the birth tub remains a cherished choice for many during childbirth, understanding the nuanced connection between sitting reclined in this tub, manual hands-on assistance, and the potential for shoulder dystocia is essential. By fostering awareness, open communication, and informed decision-making, we empower birthing individuals to navigate their birthing journey with both comfort and safety at the forefront.
Navigating Shoulder Dystocia: The Impact of Inadequate Understanding on Rising Statistics
While healthcare professionals are trained to manage this complication, a concern has emerged - the inadequate understanding of the diverse variations of shoulder dystocia, resulting in improper diagnosis, handling, and documentation. This deficiency has been a significant contributor to the rising statistics in this domain, warranting a closer examination.
Variations of Shoulder Dystocia: Unveiling the Complexity
Shoulder dystocia isn't a one-size-fits-all scenario. Its variations encompass distinct anatomical challenges, such as brim dystocia, mid-pelvis dystocia, and outlet dystocia. Each variation demands a tailored approach, precise maneuvers, and an understanding of how the baby's position interacts with the mother's pelvis. However, due to a lack of comprehensive education and training, healthcare professionals often overlook these nuances.
The Domino Effect: How Inadequate Grasp Contributes
The consequences of failing to understand the diverse variations of shoulder dystocia are far-reaching. Improper diagnosis may lead to ineffective interventions, causing delays and increasing the risk of complications. Incorrect handling techniques can exacerbate the situation, resulting in potential harm to both the mother and the baby. Furthermore, inadequate documentation leaves gaps in medical records, hindering the continuity of care and obscuring the lessons that could be learned from each case.
Escalating Statistics: A Call for Action
The statistics are a glaring reflection of this issue. Instances of shoulder dystocia-related complications, ranging from maternal injuries to neonatal outcomes, are on the rise. These statistics paint a sobering picture of the need for a comprehensive approach to training and understanding. When healthcare professionals lack the necessary skills to differentiate and manage the variations, the result is a preventable increase in adverse outcomes.
Moving Forward: A Multifaceted Approach
Addressing this issue requires a multifaceted approach. Healthcare education programs must prioritize the comprehensive understanding of shoulder dystocia's variations. Training should emphasize the importance of precise diagnosis, appropriate handling maneuvers, and meticulous documentation to ensure seamless continuity of care. Moreover, a culture of continuous learning and knowledge exchange within the medical community can empower professionals to adapt and evolve their practices.
Conclusion: Navigating the Path Ahead
Shoulder dystocia is a physiological obstacle, not a pathological challenge that demands an equally intricate understanding. The inadequate grasp of its variations, leading to improper diagnosis, handling, and documentation, is contributing to a concerning rise in statistics. It is imperative that healthcare systems, institutions, and professionals collectively acknowledge this gap and commit to bridging it. By doing so, we can ensure that every childbirth journey is met with the highest standards of care, reducing complications, and enhancing the well-being of both mothers and their precious newborns.
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