The Ordinary Doula Podcast

E90: Shoulder Dystocia

• Angie Rosier • Episode 90

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Shoulder dystocia is a rare but significant birth complication where the baby's head is delivered but a shoulder gets stuck behind the mother's pubic bone, similar to moving furniture through a doorway. 

• Occurs in only 0.5-1% of births
• Risk factors include large babies, maternal diabetes, prior shoulder dystocia, and short maternal stature
• Providers look for the "turtle sign" where the baby's head retracts slightly after emerging
• Birth rooms typically have stools ready for this emergency
• McRoberts maneuver (hyperflexing mother's legs) is usually the first intervention
• Additional techniques include suprapubic pressure, internal maneuvers, and position changes
• All-fours position is often used as a last resort intervention
• In extreme cases, intentional clavicle fracture may be necessary
• Most babies recover well, though there may be temporary arm weakness
• Mothers may experience increased bleeding or perineal tears
• Birth teams train regularly for this scenario and have clear protocols

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Show Credits

Host: Angie Rosier
Music: Michael Hicks
Photographer: Toni Walker
Episode Artwork: Nick Greenwood
Producer: Gillian Rosier Frampton
Voiceover: Ryan Parker

Speaker 1:

Welcome to the Ordinary Doula Podcast with Angie Rozier, hosted by Birth Learning, where we help prepare folks for labor and birth with expertise coming from 20 years of experience in a busy doula practice Helping thousands of people prepare for labor, providing essential knowledge and tools for positive and empowering birth experiences.

Speaker 2:

Hi, my name is Angie Rozier and I am glad to have you here with us today on the Ordinary Doula podcast. So today's subject I want to talk a little bit about something you may have heard of before, called shoulder dystocia. So shoulder dystocia is what may happen right during delivery of the baby's head being born, if one of the shoulders gets stuck after the head is born. So I want you to imagine, like moving a big piece of furniture through a doorway I don't know if you've ever done that like a wide chair, a couch, a dresser, something like that. Let's say, the front edge makes it through, fine, and that's just like the baby's head being born. That's coming out, just fine. But then one of the corners of the furniture, some other piece of the furniture kind of gets stuck, like on the doorframe. It's not totally stuck, but there's like a lip of doorframe that's holding it back. So no matter how you push, you can't get it through right. Just it won't just slide through. So what do you do? You are going to. You know, we're not just going to keep yanking and hope that it works. We're going to kind of change the angle, tilt the furniture, turn it sideways, see how you can work it to get it through more smoothly. So that's very similar to what the birth team does when there is shoulder dystocia. They'd use different positions, maneuvers to kind of help the baby's shoulders just like that lip, that furniture on a lip of a door frame to rotate and shift and come through safely.

Speaker 2:

So shoulder dystocia is not super common. It happens in 0.5 to 1% of births. So that's less than 1% of births. This happens in not crazy common. Some indicators that it happen. They're actually pretty sketchy, like it's not easy to predict. But if we have what's called macrosomia, so a baby that we think is large, and that is a little bit challenging to determine exactly how big a baby will be, or LGA large for gestational age. So if we have a suspected baby that we think is large, that increases the risk. But it's not a for sure thing that we're going to have shoulder dystocia. If the mom has diabetes, that could contribute to the likelihood of it happening. If there's been a prior shoulder dystocia, that actually could contribute to it happening. Having an operative or that means like a instrument-assisted vaginal birth, so that's like forceps or vacuums and if it happens to someone once kind of interesting to know that you have a 7% chance of reoccurrence, so it can happen again. You know the 7% chance if somebody has had it before. So bigger babies that's kind of what we're looking at here is bigger babies may sometimes get stuck and, interesting, it says short maternal stature. So if we've got like short mamas sometimes that may contribute to it, not all the time for sure, right.

Speaker 2:

So what happens is, with shoulder dystocia, the head is born and the baby's head comes out, usually like the top back of the head. You know, if you were to reach up and touch on top of your head, that's the part that presents first and then the face starts to come out and if that's happening, the head is being born and your provider can kind of know that it's going to be happening by something that we call the turtle sign. So the head's coming out and then it kind of turtles back in and that is because the anterior or the front presenting shoulder is getting hung up on the pubic bone. So it's usually that top shoulder is getting hung up on the pubic bone of the mom. So the head can come out but the shoulder can't. So if you look around in your birth room, if you're at a hospital you're going to have some fairly standard equipment around. There are going to be one or two stools that are probably like I don't know five, four or five inches off the ground and they're just hanging around in the room somewhere. Take a look for where those are. I love to use those for all kinds of things, like helping a mom to open her pelvis during labor, stand as she's standing and put one foot up on a stool. Sometimes I'll sit on them to do counter pressure or whatever. But those, those stools, are actually for shoulder dystocia, so the staff is all trained in what to do with this.

Speaker 2:

If the baby does get, they sometimes can suspect it. Like, if you kind of know what to listen for, you might realize that they're suspecting shoulder dystocia and they'll kind of get ready for it and honestly, most of the time they say that, um, it doesn't happen, like they're ready for it and generally it won't happen. I was at a birth recently where it did happen and actually this was a shorter mom. I think she was five foot or five, two, I think five foot, even something like that very short. There's no signs that she was having a very large baby or anything like that she pushed for I don't know two hours and ten minutes. So standard, you know, and long prolonged pushing stage can give an indication of shoulder dystocia, but certainly not always. So she pushed for quite a while and it was interesting.

Speaker 2:

I was listening to the team talk and stuff. We had a midwife who was delivering and nobody said anything but a nurse walked in with a second stool. There was already a stool in the room. She walked in with a second stool, a shoulder dystocia stool, and I knew just exactly what she was thinking, as well as the rest of the team. So where I was standing I was holding the mom's leg as she pushed and she worked so hard, was doing amazing and she kind of pushed that put that stool in a strategic place. So as the head was coming out, the midwife called shoulders. We got shoulder dystocia. Now sometimes there's like sticky shoulders and that sticky is like it't get stuck but it's a little sticky right, like it takes a little bit of wiggling to get out.

Speaker 2:

But when they actually do call a shoulder dystocia, there's kind of some steps they go through. They're going to recognize the turtling sign and then the shoulder won't deliver within the usual time and we want it to be, you know, fairly soon after the head. So they'll announce kind of a shoulder dystocia and people get into their zone here, like that team is going to get into their work zone. They start a clock, like a nurse will start the clock and they'll call for help, keep the patient informed as best they can, and they kind of go through a simple sequence of events where they call for help. They may, may evaluate for an episiotomy, like would an episiotomy be appropriate now? Now, episiotomy is not going to make more space in the bones, because that's what the baby's head is being hung up on, but the episiotomy makes more space for internal maneuvers and they don't jump to internal maneuvers first of all. That becomes later.

Speaker 2:

But what happens? One of the first things they'll do, it's called the McRoberts. So a nurse will get on either side and they'll push anyone out of the way who's in the way. But they'll get on either side on those stools and they'll take the mom's legs kind of way back, so hyperflex her hips and then they will add super pubic pressure to that. So another nurse, or one of those two nurses doing that, will get right on top of the pubic bone and like with the flat of her hand gives some pretty good pressure there. They used to do and thank goodness they don't, I haven't seen it for a really long time they used to do fundal pressure, so they'd go to the top of the uterus, the top of the mom's belly, and just like push down there. So we'd have somebody pushing on the pubic bone, someone cranking on the uterus, both hips or back, as they're trying to get that baby out. But they don't do any funnel pressure anymore, which is awesome.

Speaker 2:

And then internal maneuvers they'll kind of do some corkscrew to deliver that back shoulder and arm to kind of to reduce the diameter of the baby's shoulders that are trying to come through, and then kind of a last resort is getting on all fours. So they'll help that mom turn over epidural or no epidural and get on all fours, because that changes the angle of the pelvis as well. Now, kind of interesting to note. You know I'm all about movement and position and how helpful that is. If we were pushing on all fours we would already be doing the, you know, like the very most heroic thing we can do in a shoulder dystocia. So we can in effect have a less likelihood of shoulder dystocia by simply delivering in different positions, which can be good.

Speaker 2:

So last last resort would be and this is, you know, if we're not able to get this baby out and we want the baby to come out because it's Baby's getting squeezed like on their neck and things, at this point Maybe their cord is getting compressed and they're not getting great oxygenation. It's okay to sit at the perineum for a little bit, but certainly not very long. So last last resort, if they're not able to resolve this with all the maneuvers of mom's body and internally, then they'll do a clavicle fracture, like an intentional clavicle fracture of that baby, and the provider can just reach in and kind of pop their collarbone and it does. It's sad like it does break it, but that helps the baby to be born much more quickly because that gives of course a little bit more room. So I shudder to think of that. But I have seen a couple of babies not intentional, let me think, if I have. I have seen one get an intentional break with the shoulder, dystocia. But I have seen a couple break unintentionally and we're not quite aware of that for a little bit.

Speaker 2:

But there's some pretty acute coaching going on at this point. There's some pretty steady narration. Someone will take charge with shoulder dystocia. The maneuvers take 30 to 60 seconds. The nurses, everyone in their role, knows exactly what they're doing. They document it very well and they're trained. They're trained to do this. So incredibly rare. You know 0.5 to 1% of babies or deliveries is this going to be happening and it's not really very predictable. So it's not predictable. Like I told you, I've seen many, many times they prepare for it and then we just didn't even need it. They were like already there on the stools and the baby just slides right out. So maybe anticipate some quick movement and quick working and talking if that is the case. But just want you to know a little bit about shoulder dystocia and you know why it's.

Speaker 2:

A problem for the baby is it can. Being stuck can kind of mean pressure on the neck and nerves May lead to injuries, broken collarbone or temporary weakness in an arm or something. Babies can't tell us about that, but you can kind of notice in some of their behaviors. Most heal well, of course. And then for the mom, for the birthing person, it can increase the chance of heavy bleeding after the birthing person. It can increase the chance of heavy bleeding after and it can also cause more tear vaginal or perineal tears, as you can imagine, as they're doing um work with the maneuvering. So and the one you know, that's pretty true to form the birth I was at a few days ago with the shoulder dystocia, um, there was extra bleeding afterwards. They watched that mom pretty closely, um, for a little while.

Speaker 2:

But realize that your birth team, whether you're at a birth center, they can handle this, you know, in almost all cases and they're amazing at doing different positions and avoiding it in many instances. But your providers are going to be trained with steps to help free the shoulder quickly and safely. So that's adjusting legs. That'll often solve the problem right there and moving the mom's body as needed. So most people you know are just fine. They recover well when this is the case and it's actually pretty rare, which is kind of nice to know. So, just like that couch, that kind of gets stuck if you have a piece of furniture that's getting stuck in a doorframe. This is very similar, right, change the angle. In birth we use the same principles Adjusting the angle so that that shoulder can get out.

Speaker 2:

Hopefully that answers any questions you may have about shoulder dystocia. Sometimes, yeah, they say get ready for a shoulder or you know suspected shoulders. Hopefully you're not going to run into that, but I want you to kind of know and be aware of what happens. It gets a little tense for a minute, but know everybody's doing their job and they're doing their job they're trained to do. Like I said, I've only seen it a very handful of times, small handful of times in the 20 years that I've been 20.

Speaker 2:

Some odd I've been doing this, so hopefully you'll never see it. It's a pretty rare thing actually to occur. Thank you again for being here with us on the Ordinary Doula podcast. We sure do enjoy our audience and love to see the lessons that we're getting and the downloads. We appreciate that and we hope again, like always, that you will go out and make a human connection with someone today. Please, please, reach out and make a human connection, maybe somebody you've seen recently or somebody you haven't. Make a connection and make a difference in someone's life. Thanks for being here and we'll see you next time.

Speaker 1:

Thank you for listening to the Ordinary Doula podcast with Angie Rozier, hosted by Birth Learning. Episode credits will be in the show notes Tune in next time as we continue to explore the many aspects of giving birth you.