Shoulder dystocia and birthing position

[duchesse]

Something my community midwife said the other day alarmed me. It's not going to concern me directly, more likely to affect my sister whose first baby was dislodged by a hospital midwife while she was under epidural in the lithotomy position and looked rather violent tbh.

Anyway, my midwife, who is going to my attendant for my home birth, mentioned that in cases of SD she gets the woman on her back with her legs right back, as presumably they would in hospital.

I'd always (since an immense amount of reading on childbirth and optimum birht positions back in the 90s when I was expecting my first three babies) been led to believe that hands and knees or upright positions were absolutely the best positions for stuck shoulders as they widen the pelvic outlet by 1 or 2 cm. It alarms me that my 31 yr old midwife appears to have no knowledge of this position for sticky shoulders/ SD and I'm wondering how widespread this lack of awareness of the utility of different birthing positions is.

If anybody's interested particularly in SD due to a past SD experience, it's well worth googling and reading up about Ina May Gaskin and her findings on SD and stuck shoulders before your next birth, and trying to find a midwife who is aware of different birthing positions.

Thanks for this - I will have a google.

DD was 9lb 12 oz and my natural urge during the pushing stage was to stand upright and squat down. However, the midwifes were insistent I lay back on the bed with my legs right back (they had one leg each ). I was pushing for 2 hours with dd and tbh, all was well in the end and the birth was, overall, pretty good but I do remember being annoyed at not being able to stand. Apparently, I couldn't stand because they were unable to see what was going on from that position ??

I'm now pg with my second - my consultant wants to do a growth scan at 37 weeks just because dd was quite big (for me) and second dc's and boys tend to be a bit larger so they are potentially concerned about SD.

Tilly, if you google "best birth position for shoulder dystocia", one of the first sites it turns up is a midwife's personal site about two experiences of SD. One mum delivered standing up with no tears or problems a very large baby after a previous bad experience, the other chose to flip onto her back and had an experience like your first. Obviously a very small sample, but possibly vindicates your desire to be upright!

This one.

I had SD with my DS, born 2 years ago. We tried to get him out with me on all fours but it just didn't work - I had to lie on my back so the MW could push down above my pubic bone while another MW held the baby's head.

I think that being aware of birthing positions is all well and good, but if a baby is stuck then he needs to come out RIGHT NOW and frankly I wasn't about to argue with the crash team who filled the room!

Thankfully my DS was fine, but a colleague of my mum's sadly lost a baby after SD and being unable to birth him quickly enough - he died after severe lack of oxygen.

I did Ina May/Sheila Kitzinger etc etc - had planned a homebirth - but sometimes the 'all fours' thing just doesn't work, and in this situation it's really not something the MWs like to experiment with as time is of the essence!

Actually the maneuver your MW is describing is one of several that Ina May has had success with - check out this article on The Farm website: www.thefarm.org/midwives/dystocia.html

Getting on all fours is the first step in a series of actions for a MW to perform in a true case of SD. So dismissing all fours without knowing what else can be done is not fair.

FWIW SD is a problem for large and for avg / small babies. But MWs and Consultants tend to shroud wave when they believe a large baby is on the way.

Many cases of SD has to do with the positions mothers are expected to before the baby gets stuck so good positioning before the pushing stage is also important. unfortunately a lot of MW expect talk mothers into assuming positions that make it easy for them to see rather than letting mothers assume an optimal position birthing. It makes me wonder who labour and childbirth actually put out.

Is there any way of finding out if a previous SD affects your chances of SD in subsequent pregnancies? Would I automatically be in a higher-risk category - i.e. would I have to fight harder if I wanted a homebirth with any future pregnancies?

I was lucky enough to have a community midwife present throughout my labour/birth, laboured in the pool, stayed active - and still had SD! The only part of my birth that I was on my back for was the delivery after the SD!

I think there is a big difference between encouraging a woman to be on her back for her entire labour (which, from what I've read, could well encourage SD), and using McRoberts manouevre (woman on back, knees moved to shoulders to change angle of pelvis, with pressure applied above pelvis) in a case where SD is already present.

I would strongly resist the former, but would go along with the latter in a flash if a MW that I trusted told me it was necessary. My guess would be that the MW was talking about the latter scenario and something that should would do in an emergency rather than recommend you lie on your back throughout - but it would be worth clarifying with her if you're worried

I had SD at my homebirth, despite delivering (or trying to deliver) my son in a kneeling position. My independent midwife got me into McRoberts and got baby out that way.

The 'Gaskin manouvre' involves turning women who have SD from their backs onto all fours, which probably works very well with women who are on their backs in the first place (you'll notice that in the first Spiritual Midwifery many of the women are shown birthing on their backs), but how well it works with women who are already on all fours...... There's some argument that it's the change of position that can free the shoulders, rather than the position itself that makes this manouvre effective. But McRoberts is very effective too - in essence you're doing an extended squat on your back!

I had a SD birth with my third baby. I was in the birthing pool,the midwife had not realised he was stuck although i had said i was pushig and nothing was happening,she told me to stans up and put my foot on the side of the birthing pool. I did this and it worked although as i stood up i stepped and smashed the mirror so had to get out the pool straight afterwards.

extrafancy After i had DS the midwife said i would not be allowed a water birth with another baby so i am guessing that you may have a higher chance of having SD if you have already had one.

if you want to see good dialogue about SD I suggest joining the Home Birth yahoo group and asking a Q there yourself and / or searching their archives.

If a MW was to tell me that having one SD puts me at higher risk of another one, I would be asking her for evidence based information to back up what she had said. From what I have read, there doesn't seem to be any evidence to back up that statement.

This is pretty informative.

www.rcog.org.uk/womens-health/clinical-guidance/difficult-birth-what-shoulder -dystocia

pseudoname I don't think i will have another baby but if i did i would speak to the consultant in charge of my care to see why the policy stands,i would want to use the birthing pool for at least some of my labour.

Sorry this www.rcog.org.uk/womens-health/clinical-guidance/difficult-birth-what-shoulder-dystocia

extrafancy I had SD with DD. She suffered erbs palsy because of this and her arm was completely paralysed for a month. Luckily with physio she has mead a great recovery and you would never know now! I am now 35 weeks pregnant and I am considered high risk I'll have to have a growth scan at 36 weeks to decide if the baby is too big to be delivered by VB. If it is predicted to be the same size as DD or larger (which was only 8lb) I will have to have a C Section to avoid it happening again as there is a higher risk once you've had one. Also, is I choose to try for VB (which I'll only do if the baby is significantly smaller) I'm told that the most senior obstetrician on staff will have to deliver the baby so that any problems can be delt with quickly and intervention will not be delayed. SD can be very serious and it's just not worth the risk IMO. I have a friend who suffered SD with her 2nd DS and he has erbs palsy and cerebal palsy as a result .

Thanks for that link skybright, I was one of the women with a baby under 4kg who suffered this. Unfortunately for me, they did not do any of the procedures listed the link to help, rather they just emptied my bladder with a catheter (ouch!) and pulled DD out with a ventouse, which probably contributed to the outcome. Is good to have this information in case I am able to go for a VB this time and I'll insist they try these should there be any trouble!!

Thanks for that info - I was actually part of the Yahoo Homebirth UK list during my pregnancy, but after choosing to have my baby in hopsital on advice of my MW, I got the feeling that my birth story wasn't really welcome/wanted there!

The insinuation that the SD was somehow my fault for not staying at home/not being in the right position sort of irritated me TBH and I would definitely take the advice of my MW over the internet any day.

Best of luck duchesse in finding what is best for you and your current circumstance. The support I had from the NHS was, overall, pretty poor when I was having both DDs. I found stuff on the net far more informative than what I got from my midwives, HVs or Consultants. I think the key is being able to trust yourself in knowing how to evaluate evidence based info on the net or be confident that your HCP are following evidence based guidelines which suit your current circumstance best.

extrafancy I can't believe that people were insinuating that the SD was somehow YOUR fault is beyond me! The fact that you had a hospital birth probably saved your baby's life, not damaged it!

I have my appointment and scan with my consultant next week to discuss birthing options and I will definitely be taking on board their comments as they are the experts who I will have to entrust my baby's life with.

My cons used McRoberts on me when I had dd - MW (who was great) was setting up for forceps, but he tried the McR and it worked well. Had a little tear, but nothing substantial, and dd was 10lb 11oz. At the time my legs were jelly - I'd been on all fours, with lots of support from mw, but collapsed for a rest and couldn't get up again! Next time I'll try and stay up and about more if I can, but agree that McR isn't the same as just delivering on your back - it really does open up the pelvis.

Habbibu I'll have to keep that in mind if I end up having a VB! Good to hear that they actually use these manoeuvres in hospitals and don't always go for forceps/ventouse/emergency CS.

Well, the MW, who was lovely, was setting up for a forceps delivery - it was only when the consultant arrived that he decided to try MacR - took away the g&a, mind! He's pretty non-interventionist, mind - not a big fan of sweeps and inductions, etc, so I think I was lucky that he was around that day.

"Good to hear that they actually use these manoeuvres in hospitals and don't always go for forceps/ventouse/emergency CS"

My understanding istat instrumental births are generally contraindicated in the case of SD - this is how a lot of damage can be done to babies and to mum. If the baby's shoulder is impacted on the mother's pubic bone then how can simply applying traction to the baby's head help resolve this? I appreciate that forceps and ventouse are used to rotate babies sometimes, but I cannot see this working well in the case of a proper shoulder dystocia.

And unless the consultant does something called a 'Zavanelli' manouvre (very rare), which involves flexing the baby's head and rotating/pushing it back up into the womb, a c-section is generally not an option in the case of SD!