Looking for something? Start here.
Custom Search

 

Want The Unnecesarean in your inbox? Enter your email address:




 

   

« ACOG Survey: Complications Related to Home Delivery | My Baby is Four »
Wednesday
Aug262009

Misdiagnosis of Shoulder Dystocia: Bed Dystocia and Snug Shoulders

Share on Facebook

 

The incidence of shoulder dystocia is generally reported as less than 1 percent. According to Varney’s Midwifery, shoulder dystocia may occur from 0.2 to 2 percent of vaginal cephalic deliveries, yet an accurate figure probably does not exist due problems with accurately establishing the incidence of shoulder dystocia. The textbook also notes that defining shoulder dystocia is critical to determining what steps to take to resolve it. The basic and anatomically correct definition of shoulder dystocia refers to cephalic presentations in which the anterior shoulder is wedged above the symphysis pubis instead of entering the true pelvis; however, in the clinical setting, the diagnosis is subjective and based retrospectively on observation. (Varney, p. 883)

Varney’s Midwifery cites two closely related types of dystocia that a midwife must be able to accurately diagnose as separate from actual shoulder dystocia— bed dystocia and snug shoulders.

Bed dystocia occurs when the woman is in a semi-Fowler’s or similar propped-up position and the baby is being born downward into the bed. Bed dystocia is especially common with a soft bed that sags under the woman’s buttocks. In such a situation, there is no room for delivery of the shoulders. This, however, is not shoulder dystocia. The problem is readily rectified by slipping something under the woman’s hips that elevates them and by reducing the upright angle of her position in the bed; or by bringing the buttocks to the edge of the bed; or by turning her on her side into the hand-knees position. It is an error to record such an event as an incidence of shoulder dystocia. (Varney, p. 884)

Often mistaken for shoulder dystocia are snug shoulders.

Snug shoulders are often given the misnomer “mild” shoulder dystocia and most likely do not meet the definition of the impingement (or impaction) of the anterior shoulder or both shoulders above the pelvic brim. Snug shoulders can occur with a large baby, an adequately shaped pelvis, and a somewhat obese mother, which together comprise a soft tissue dystocia. The head is born very slowly but the midwife does not need to push the perineum back manually in order for the head to be born. The baby’s face is fat but the baby does not really exhibit the turtle sign as the head goes through both resuscitation and external rotation. The shoulders are tight and take more effort to deliver, but making sure the shoulders are in the oblique diameter of the pelvis, a little suprapubic pressure, and an exaggerated lithotomy position readily take care of the problem, as does having the mother get into the hands-knees position. (Varney, p. 884)

 

The hands-knees position is widely known as the Gaskin Maneuver, named for midwife Ina May Gaskin. The following precautions can be taken to help reposition a woman in the event of a shoulder dystocia, according to the article “A New (Old) Maneuver for the Management of Shoulder Dystocia” on The Farm’s web site:

It takes surprisingly little time (as little as 30 seconds) to get a patient to her hands and knees, even in the event of an unexpected shoulder dystocia, such as the one reported here, and it can be accomplished even more quickly in a patient with more than one known risk factor if the following precautions are taken in advance:

1. Encourage the mother to assume the all-fours position at intervals during labor. It is a very comfortable position, especially when the baby is occiput posterior, and it is useful for facilitating rotation and descent. Admittedly, not all mothers will be comfortable in this position, or it may be one of many different positions assumed by the patient during the course of her labor, but it will help if she becomes familiar with this position in advance of the birth. Advise her that it may become necessary to assume this position again for delivery of the shoulders.

2. Avoid intravenous lines. A heparin lock can provide emergency venous access without the restrictions of dangling IV lines.

3. For the same reason, avoid continuous electronic fetal monitoring equipment, or remove the belts as the vertex is delivered. Belts and cables are also restrictive, and studies have shown that auscultation of the fetal heart tones every 5 minutes during the second stage of labor is sufficient.

4. Along the same lines, avoid stirrups and extensive sterile drapes, and for obvious reasons, avoid epidural anesthesia.

5. Have at least two assistants present at the birth. Labor coaches can be helpful in facilitating rapid changes in position if necessary.

6. Finally, deliver the baby in a bed, not on a narrow delivery table. Consider using the lateral decubitus position, or better yet, complete the entire delivery in the all-fours position in those patients at high risk for a shoulder dystocia (Table 1).

Admittedly, these recommendations run counter to the whole technological approach to childbirth that has been developed over the past 20 years, and they are not likely to be adopted in large traditional centers. Although anecdotal reports indicate the maneuver has been used successfully in high-tech settings, we expect it to prove most useful in the context of the low-intervention approach to obstetrics that is most familiar to family physicians.

 

Varney, H., Kriebs, J., Gegor, C., & Varney, H. (2004). Varney’s Midwifery. Boston: Jones and Bartlett Publishers.

 

Bookmark and Share       

PrintView Printer Friendly Version

EmailEmail Article to Friend

Reader Comments (6)

Bed dystocia, eh. I hadn't heard that one before. Interesting.

August 27, 2009 | Unregistered CommenterJill

You know I love these SD posts ;)

I also think that many hospital room dystocias are really bed dystocia, or just the doc jumping the gun and freakin out if there is even the slightest delay in head to shoulder delivery.

I was just watching a youtube video the other day about birth trauma in babies, due to being pulled out of the mother by their heads during delivery. Watching the video was very difficult. As soon as the docs were about to hook their fingers underneath the baby's chin, they were literally yanking their heads up and down, left and right. It's as if they just want to get that baby OUT asap--afraid of SD or who knows what else. They also showed the yanking being done during cesarean delivery too. The video made we wince.

August 27, 2009 | Unregistered Commentermichele

Michele, do you really love them or do they freak you out? I read about it a lot because it seems to come up in every single suspected macrosomia/prophylactic cesarean recommendation speech. I always think of you when I post about it.

There are some ROUGH delivery videos on YouTube. I've had to stop watching some roughly managed births because it's too much to stomach. It's one thing if there's an actual emergency, but when it's just rushing a spontaneous vaginal birth... yeesh.

August 27, 2009 | Registered CommenterJill

I too have seen many aggressive approaches to deliveries from fear of a shoulder dystocia occurring. I wonder how often this aggressive approach ends up leading to more problems then would have otherwise occurred. Granted, a shoulder dystocia is one of every providers' worst nightmare. But it's unreasonable to practice as if every woman might have a shoulder.

Hooking fingers under the baby's chin is bad bad bad - more likely to cause damage!

As a student midwife I was told various different things in regard to manuevers at birth to prevent shoulders. For example, one preceptor told me not to wait on restitution to have the shoulders deliver. Someone else said wait for restitution. I have gone for a more hands off approach as I have gained more experience.

August 29, 2009 | Unregistered CommenterTiffany

Yep, bed dystocia. We also have fat dystocia, doctor dystocia, family dystocia.

August 30, 2009 | Unregistered CommenterVickii

I seem to have more than my share of shoulder dystocias/sticky shoulders. I wondered for a long time if it was that the women I had had chosen the "wrong" positions to birth in, but they have occured with other midwives as primaries, too. In fact, one awful one was with my former apprentice in HER birth. I've seen how midwives tend to get more of certain complications than others. One midwife in our community has an inordinate amount of hemorrhages; hence, she is extremely skilled in managing hemorrhages. If I had a shoulder dystocia, I would want me as the provider (sounds arrogant, but I feel I work very clearly and in an un-panicked way when the situation presents. I am often asked to teach students about sd and am always glad to share my experiences.

All that said, to me, the Gaskin Maneuver works because the pelvis is opened *as* the woman is turning from back to hands and knees. I find stopping mid-turn... *lunging*... a much more effective help in resolving stuck/sticky shoulders. I have women lunge one way and then the other, sometimes a challenge with a huge head between the legs, but with manual assistance, it has worked more than hands and knees on its own. Plus, I can't recall the last time I had a woman choosing to birth in her bed on her back semi-sitting (surely at Casa in 2002), so moving them to hands and knees doesn't open the pelvis as much as if they were in bed.

We saw women with the head born, but the body not coming, lift their leg out of the pool and the baby falling out; Sticky shoulders there. If a woman gets out of the pool and the head is still stuck, then as more work is done, following the routine of sd corrections is called for.

So, I the best position I have found for relieving both sticky and dystocia'd babies is McRobert's. It *does* affect those women in soft beds (we saw plenty of bed dystocias at Casa... soft beds, heavy moms). Supra-pubic pressure is fantastic. "Unscrewing" babies out is very, very difficult when they are really stuck... sometimes it's incredibly hard to get hands into the perineum. I have never cut an episiotomy for any of the sd's I have attended. I don't find them necessary (or haven't yet), but wouldn't hesitate to do so if I felt it would help. (Standard protocol says episiotomy is one of the first things to do.)

Vickii briefly mentioned fat dystocia. Fat women just don't like hearing that their vaginas *are* fatter than women who are standard-weighted. (As a fat woman, I can tell you it's true and I am able to discuss this without being fat phobic.)

Two very difficult sd's I've had (one as an assistant, the other as primary but working with mom at her shoulders) were both VBACs... one with an 11 lb. 11 oz. baby and the other with an 11 lb. 6 oz. baby this mom also hemorrhaged so badly she had to have 2 bags of blood. She'd torn a blood vessel in her posterior fornix that we couldn't see. The doc's found it with the weighted speculum and opening her vagina very, very wide.). I've only had one sd baby that was under 10 pounds.

As far as the midwife waiting for restitution versus managing the birth *before* restitution, I have found delivering *before* restitution much more effective. It is what we used to do at Casa, but because clients are not in beds, that isn't something I have done in years, but sure wish I could sometimes! The worst is when babies are *so* stuck that they don't resitute at all.

Just wanted to add a few thoughts. Thanks for listening to it all!

September 4, 2009 | Unregistered CommenterNavelgazingMidwife
This blog is all done!
Thanks for wanting to comment. This is an archive of a blog that once was. Take care! Jill