Birth Complications – Shoulder Dystocia

Maternal and fetal complications during the birth of a baby are some of the most feared problems in medicine, for a lot of reasons. The truth is, most complications that are severely detrimental to mother and/or baby are rare. You can see my post Special Topic: Death in Childbirth for more information.

Perhaps one of the most feared by modern obstetric practitioners is the complication called shoulder dystocia.

Shoulder dystocia occurs in about 1% of all modern human births. It happens because one (or rarely, both) of baby’s shoulders gets stuck behind the bones of mom’s pelvis.

This is a dangerous situation for mother and baby, as umbilical cord may be compressed if it is wrapped around the neck, preventing baby from getting adequate oxygen. Further, both mom and baby may experience exhaustion, trauma (including uterine rupture), and death if this situation is unresolved.

During a normal, vaginal birth, whomever is helping mom birth the baby should apply a gentle downward pressure on the baby’s head to help deliver the shoulders during a contraction – either immediately after the head is born or on the next contraction if baby’s nose and mouth can be suctioned while the body is still in the birth canal. This gentle downward pressure should be sufficient to help baby’s shoulder disengage from the pelvis and baby should slide out quickly (catch!). If baby stays stuck despite gentle downward pressure on the head, shoulder dystocia may be the problem.

Fortunately, shoulder dystocia is not a death sentence. There are a number of “maneuvers” that can help get that kiddo out. Whoever is helping with this dramatic type of delivery has a few options. The best option and least invasive option is just to get the mom up on hands and knees. This changes the angle that baby is approaching the pelvic outlet a bit and also creates more room for baby to turn. Unfortunately, in modern births this is often unable to be performed due to the use of epidural anesthesia. Further, a lot of modern doctors are simply “uncomfortable” attempting to delivery baby in an unfamiliar position (poor them, right?) so a number of other, physician-guided maneuvers have been invented.

Another option, particularly for women who are unable to go into the hands and knees position, is called the McRoberts Maneuver (see comments), and involves pressing the legs up toward the chest while the mother is in a semi-flat position on her back. This also widens the pelvic outlet. At the same time or separately, an assistant can use the heel of his or her hand to press down firmly on the baby’s stuck shoulder, just above the mother’s pubis – the ridge of cartilage that connects the pelvic bones in the front – using the same sort of position someone might use to perform CPR compressions on the chest (generally with only one hand though).

If that doesn’t work, your doc or cabby gets to go where at least one man has gone before. Inserting at least two fingers behind the baby’s stuck shoulder and applying firm, gentle pressure to rotate the shoulder away from the pubic bone can allow passage of the baby. Be careful here not to put rotational force on the baby’s head, though. This maneuver may require pressing the baby back up into the birth canal a little bit (between contractions) to give enough room to move the shoulder.

If there isn’t enough room for fingers in the canal, an episiotomy can be performed – this involves cutting the perineum (the skin and muscle between the vagina and the rectum). The cut generally extends about halfway between the two, although larger cuts and tears sometimes occur. Episiotomy will not help the shoulder dystocia itself, but it will allow doc more room to play, so to speak. If at all possible, this should be done using sterile instruments only – the risk of post-partum infection to mom otherwise is enormous.

If all else fails, a trained physician may attempt to utilize some last-ditch efforts, like intentionally breaking the baby’s shoulder or arm or using a Cesarean cut to give him or herself a chance to reach into the womb, rotate the baby, and allow the birth. The most risky maneuver involves attempting to push the baby’s head back into the birth canal to delivery via C-section. In developing countries, physicians who have very limited resources sometimes cut the mother’s pubic cartilage under local anesthesia rather than performing a Cesarean cut. The first few options on the page should take care of ~90% of shoulder dystocias, though. Keep in mind that this is a pretty rare occurrence to start with, and the last ditch efforts should be fairly rare.

That said, modern births do occur outside the statistical norms in a lot of ways. Almost 30% of births in the United States are performed by surgical removal of the fetus, but shoulder dystocias still occur at about the same rate in vaginal births because they are difficult to predict, despite a number of decades of measuring pelvises and guessing baby-weights. Women considered to be more at risk for shoulder dystocias include those of short stature and who have gestational or other forms of diabetes. Large babies >9lb are also at increased risk, but it is practically impossible to predict which women and which babies will be affected. Even given the risk factors for this condition, vaginal birth results in a much lower rate of complications for both mom and baby than routine surgical delivery.

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Remember, information at Muse Medicine is for fiction writers ONLY and should not be construed as medical advice or applied to real people. Please seek a licensed physician for questions regarding your personal, real-life situation.