Shoulder dystocia can be a serious birthing complication that makes itself fully known after the birth of the baby's head and then the shoulders fail to follow. It is more common when the baby is very large, or the mother's pelvis is very small. Sometimes you can tell the shoulders will get stuck when the head is born. The head may take lots of hard pushing to be born, instead of coming out smoothly after it crowns. Sometimes the baby's chin doesn't quite come out. It will appear that the baby's head is being pulled back into the mother, resembling a turtle pulling it's head into its shell. As soon as the head is born, it will seem to pull tight against the mother's skin. The neck will not be loose. Often the baby will not turn to face the mother's thigh. Even hard pushing will not bring the shoulders out.

DANGER!
Shoulder dystocia occurs when the baby's anterior shoulder becomes impacted behind the mother's pubic bone due to the shoulder girdle being to broad to pass through the anterioposterior dimension of the mother's pelvis. On top off the impacted shoulders, there is a great deal of chest compression for the baby because of the squeezing of the birth canal against the chest region. Because the chest is squeezed so tightly, the venous return from the head can be impaired and can lead to intercranial bleeding, brain damage, and death if not handled swiftly and competently by the midwife or birth attendant.

The midwife should anticipate this problem if the mother is expecting a baby that may be large for her pelvic dimensions. It is important to remember that if the head can pass through the pelvis, so can the shoulders, although it may take some position changes and maneuvering by both the mother and the midwife to accomplish this feat.

Signs to look for include:

An unusually large head passes over the perineum.

The large head retracts against the perineum (the turtle sign).

Restitution takes place slowly, haltingly, or not at all.
These occurences are due to shoulders being too high in the pelvis to allow the head normal freedom of movement.

Checking for cord around neck is difficult.

No shoulder presents

The baby's color rapidly deepens to dark purple.

Despite pushing efforts of the mother and reasonable downward traction on the baby's head, nothing changes.

A dignosis is made.... Shoulder Dystocia.

Depending on position of the mother, perform appropriate maneuver.

Squat Position: Getting the mother up into a squatting position opens up pelvis and may dislodge the shoulders.

Hands-Knees Posture: Rolling the mother over to a hands-knees position will often rotate the baby out of the anteroposterior diameter to the oblique, making the delivery of the shoulders easier. Hands-knees promotes full pelvic relaxation, and enhances the midwife's ability to maneuver. Make sure the mother's head is higher than her hips.

Cup your hands around the baby's head and pull downwards towards the mother's belly while counting to 30. When you see the shoulder, pull up and deliver normally. If this does not work, try the next method.

With the mother still in the hands and knees position, put your hand inside the vagina along side the baby's back. Position your fingers on the back part of the shoulder which is nearest to the mother's back.

Try to push the shoulder forward until it moves to the side. Try to deliver the baby in the usual way, pulling downward whild counting to 30.

If the shoulder does not deliver spontaneously with this, use the "Screw Maneuver" below.

Screw Maneuver: Reach inside the perineum to the posterior shoulder, and place two fingers in front of it, against the juncture of chest and armpit. Take care not to hook fingers in the armpit as this can cause nerve damage. Rotate backwards, pulling the baby outwards at the same time (with a screw-like motion). This should dislodge the anterior shoulder, collapse the shoulder girdle and bring the baby out. A 180 degree turn is usually enough to free the baby, though occasionally the midwife may need to reverse this process for the other shoulder.

McRoberts Position: Another alternative position in which the mother is fully supine with her knees hyperflexed. This posture lifts the pelvis off the bed, increasing flexibility of the joints and available room to maneuver. The midwife should have an assistant gently lift the baby's head towards the mother's pubic bone, or the midwife can do it herself as she hooks two fingers behind the posterior shoulder and move it to an oblique position. Often just rotating the bottom shoulder will allow the baby to be birthed.

Extracting an arm will further reduce the diameter if necessary. To extract the arm safely, the midwife must splint the arm with two fingers and sweep it across the chest, allowing her to grasp the baby's hand and complete the maneuver.

(1)Put your hand inside the vagina and up along the baby's back. (2)Move your hand around the baby's body, bend the baby's arm, grasp it's hand, and bring it across the chest to (3)pull the hand out of the birth opening. (4)The baby can now be born fairly easily. Grasp the baby by body (not the arm) for the birth.

Suprapubic Pressure: It sometimes will help if the midwife has her assistant give suprapubic pressure to help dislodge the anterior shoulder. Suprapubic pressure should be applied at an angle, from behind the baby's shoulder and towards its face, rather than straight down. Don't confuse this with fundal pressure, which will only impact the shoulder further unless it is given in conjuction with firm suprapubic pressure. This may be necessary if the posterior shoulder cannot be reached.

Clavicle Fracture: It might come down to this if all other methods above have not worked and the baby simply refuses to move by rotation in either direction and the situation has become critical. This extreme measure of breaking the baby's clavicle should only be used as a last resort to save the baby's life. By breaking the clavicle, this collapses the shoulder girdle and the baby delivers. This is a horrible thing to have to do, but it is better to have to do this then have a baby with brain damage or death. To break the clavicle, position two fingers against the anterior surface of the collar bone, open your fingers slightly, then place your thumb behind the bone and push between your fingers. It should be like breaking a small stick. The clavicle is to be broken outwards to prevent a lung puncture and the baby will need to be seen by a pediatrician immediately. Howver, the clavicle does heal quickly.

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The midwife should have her assistant to keep track of time passing, announcing time lapsed at interval of 30 seconds during the maneuvering. These positions can be tried in any order until success is achieved.

An episiotomy may need to be done. It this is done, be prepared for tearing and having to do repairs after the baby is born. If the tearing is beyond suturing at home, the mother may need to be transported to a medical facility after the birth for repairs.

Also be prepared to perform neonatal resusitation (NNR) and possible transport to a medical facility if the baby does not respond well after the birth. Babies may be a little slow in getting "started" after a difficult delivery.

Carefully observe both mother and baby after the birth, making sure both are doing well and all are fine before leaving the birthing scene. The baby having had shoulder dystocia should be checked carefully for bruising, injuries to the clavicle bone, or possibly Erb's paralysis due to nerve trauma. Severe dystocia is an automatic indication for vitamin K. A pediatrician should be consulted if anything is abnormal.

MoonDragon's Pregnancy & Birthing Survival Tips

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