Shoulder Dystocia

complication intervention

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There is a lot of unwarranted fear about 'big babies' getting stuck, and the usual story is that women are creating a problem by being unhealthy and growing massive babies. This is interesting in itself because poor maternal health is associated with growth-restricted babies rather than larger babies. The incidence of shoulder dystocia does increase with the size of the baby. However, complications associated with big babies are not necessarily about the size of the baby. For example, if a care provider suspects a ‘big baby’, the woman is more likely to experience interventions and complications regardless of whether her baby is actually big (see this post for more details). This post will discuss how to avoid shoulder dystocia (if possible) and deal with the situation if it occurs.

What Happens During a Shoulder Dystocia?

Basically, the baby's shoulder/s gets caught in the pelvis. Most diagrams and depictions of shoulder dystocia show a baby becoming stuck on the symphysis pubis (the pubic bone) at the brim of the pelvis. However, a baby can become stuck in any part of the pelvis (more info about the pelvic brim, cavity and outlet in this post). 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 shoulder dystocia as particular actions are ineffective for particular types of shoulder dystocia.

Avoiding Shoulder Dystocia

A lot of midwifery and obstetric learning resources focus on how to manage complications or problems rather than on how to prevent them from happening. Although, in some cases, shoulder dystocia is unavoidable, there are a number of ways to reduce the chance of it occurring:

Undisturbed birth

When women are able to give birth instinctively without direction or intervention, they are capable of instinctively fixing problems themselves. I have seen some bizarre birth positions and movements that made perfect sense once the baby emerged. And, in the case of a stuck shoulder, instinctive pelvic movements can release the baby without drama. The first step in risk management is to promote and support instinct and physiology. (see this post)

Patience

The baby needs time to get into the best position to move through their mother's pelvis. When we try to hurry birth, the baby may be unable to make these adjustments. Directed pushing can force the baby into the pelvis without allowing time for subtle adjustments to happen. Syntocinon (Pitocin) induced contractions can do the same. I am also convinced (but have no research to back me up) that pulling babies out can wedge their shoulders against the pelvis. Waiting for a contraction when the baby's head is out can feel like forever, and it is tempting to tell the mother to push or pull on the baby. But, the baby may be using this time to make the adjustments necessary for their shoulders to birth. I share a video of a big baby wriggling his shoulders around in between contractions in my Big Babies Lesson Package. As long as there is some change with each contraction and the baby is well, you can wait. Bite your tongue and sit on your hands if you have to. Usually, the shoulders will be born with the next contraction following the head, but not always. The next contraction may rotate the baby; then, the next contraction births the shoulders. Watch and see. I have noticed that many babies do not follow the textbook description of the 'mechanism of birth' and instead emerge with their shoulders lateral or oblique to the pelvis rather than anterior-posterior. It is best not to force a 'mechanism' on an individual baby/situation.

Being proactive with epidurals

An epidural will alter the physiology of birth and the instinctive behaviour of the mother. Once an epidural is inserted, 'active birth' often goes out the window. In my opinion, 'active birth' is not necessary when a woman is undisturbed because she will instinctively get into positions that work for her without prompting. However, active birth becomes essential for a woman who has an epidural. Looking after a woman with an epidural should be hard work. As a care provider, you now have to help the baby rotate through the pelvis by prompting and assisting maternal movement and position.

Birthing in a semi-recumbent position increases the chance of shoulder dystocia because the pelvis is unable to open; it prevents the sacrum from moving backwards and the coccyx from uncurling. This is often the default position for women with epidurals. However, the woman doesn't need to be upright or squatting to allow her pelvis to open. Research into the benefits of an upright birthing position was carried out on women without epidurals. In contrast, a study looking at pushing with an epidural found that a side-lying position increases the chance of a spontaneous vaginal birth by 5.9% compared to an upright position [1].

I have a lesson on how to improve outcomes for women with epidurals in my Medical Birth Lesson Package.

Management of Shoulder Dystocia

Despite anything and everything that mothers and care providers do, some babies will still get stuck. Even though shoulder dystocia is relatively uncommon (1:200), knowing what to do is useful. Firstly, it is important not to make a bad situation worse, therefore:

Do not pull the baby, as this will impact their shoulder further. Initially, diagnostic traction may help you know if the baby really is stuck, i.e. gentle firm traction. If the baby is stuck on soft tissue rather than bone, they will move. If not, stop. Pulling is the most common mistake people make because they panic. Excess traction can result in brachial plexus injury to the baby. Unfortunately, the care provider can then find themselves facing litigation.
Do not cut the umbilical cord if it is around the baby's neck. While the cord is intact, there is still a chance that the baby is receiving oxygen, which gives you more time and assists with resuscitation afterwards.
Communicate with the mother. You always have time to explain what is happening and get consent for actions.

We all learn and retain information differently. As a midwifery lecturer, I taught two types of approaches: standardised and situational.

Standardised approach

These structured approaches are good for those who find it easier to remember systematic step-by-step information and prefer to work through set techniques systematically. Although standardised approaches are general, and some of the manoeuvres will not work for variations of shoulder dystocia, they are effective for most scenarios. The main standardised approach is taught within hospital system to doctors and midwives is HELPERR.

H = Call for Help
E = Evaluate for Episiotomy
L = Legs: McRoberts Manoeuvre
P = External Pressure - suprapubic
E = Enter: rotational manoeuvres
R = Remove the posterior arm
R = Roll the patient to her hands and knees

I have a strong aversion to mnemonics. I get particularly frustrated by mnemonics that don't fit the letters to actions, resulting in actions being crow-barred into the word or another letter being added so it is no longer an actual word. In the case of HELPERR, the first E is for 'evaluate for episiotomy', which I have yet to see anyone seriously do in real life. Firstly, you would have to be very brave to attempt putting scissors in such a tight space next to a baby's head/face. Secondly, if you really need to get your hands in, you will, and a tear will be the least of your worries at that moment. I have heard that 'E' is sometimes used for 'explain', which is much better. Another problem with HELPERR is that it assumes the woman is on her back - which I guess she usually is if the baby is stuck. The first two manoeuvres, 'McRoberts' and 'suprapubic pressure', are only effective when the shoulder is stuck on the symphysis pubis. Otherwise, they are a waste of precious time.

I know that some people find mnemonics assist them in remembering sequences and that hospital staff are expected to follow them. I can see the place of this approach within a hospital setting where a range of practitioners with a range of skills and experience may be dealing with an emergency. At least everyone knows what comes next, and I have seen it work well for a group approach to the problem. In addition, for legal purposes, it looks good if you have documented evidence of working through the HELPERR sequence. I am not going to detail how to carry out the manoeuvres here because anyone working in maternity care has regular updates on managing shoulder dystocia, and you can find demonstrations easily online.

The limitations of the HELPERR approach become apparent when assumptions about position (reclining/on back) and environment (on a hospital bed) are removed. If shoulder dystocia occurs in a small toilet cubical with an upright woman, how do you perform McRoberts? Or, if the baby's shoulders are stuck mid-pelvis or on the sit bones, the first techniques in HELPERR will be ineffective.

Situational approach

Considering the range of positions, environments and situations birth takes place in; and the variety of places shoulders can get stuck, another approach is to think and act beyond a mnemonic. We also need to keep it simple and quick. When shoulder dystocia occurs, one or both of 2 things need to happen to release the shoulders:

1. Change the size and position of the pelvis (mother)

This can be done by encouraging the mother to move and change her position. The best option will depend on the position she is already in. Often, just the movement of getting into a position will release the baby. You can ask or assist a mother in changing her pelvis by lifting a leg up and/or outwards, e.g. onto the side of the birth pool or chair. This can be accompanied by a rocking back and forward of the pelvis (thrusts). Or, If the woman is on all fours, flipping over onto her back may release the baby. In a forward-leaning position, the baby's shoulder is likely to be stuck on the symphysis pubis. There are many ways a woman can change the size and position of her pelvis. If you have a good understanding of where the baby is stuck, it can help with working out what movements will work.

2. Change the size and position of the shoulders (baby)

Adducting the baby's shoulder/s will make the diameter of the shoulders smaller. Rotating the shoulders into the oblique diameter of the pelvis will make use of the extra space available. There are many ways of achieving adduction and/or rotation of the baby's shoulders. The manoeuvres included in HELPERR will do this. There are also less well-known methods, such as axillary traction [2], and when I taught shoulder dystocia workshops, midwives shared lots of creative techniques that they had found effective.

There is no particular order in which you can try positions and actions in a situational approach. It will depend on how well the mother can move, the position she is in, and the access you have into her pelvis, i.e. how and where you can get your fingers in (if needed). Bear in mind that there is more room in the back of the pelvis than the front, and this room is best accessed when a woman is forward-leaning, i.e. the opposite of HELPPER.

It also really doesn't matter what the manoeuvres are called or where exactly you place your fingers. Or even where the baby is stuck if you don't know. Essentially, put your hand in, find the baby (shoulder, back, chest) and rotate them round and out. Ideally, you will be applying pressure to the back of the shoulder, but if not, the baby is still likely to rotate; the shoulders/chest are all connected and will move together. The important thing is to get the baby out, and getting caught up in exacts can create more stress and delay.

A situational approach assesses the holistic situation and uses the appropriate movement or action at the time. I provide demonstrations of manoeuvres in the lesson on shoulder dystocia in my Big Babies Lesson Package.

Summary

Shoulder dystocia is more likely to happen if a baby is big. However, shoulder dystocia is often caused by disrupting physiology and instinct with unnecessary interventions. A shoulder dystocia can be resolved using a standardised approach or a situational approach.