Episode 220 - Shoulder Dystocia
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
[0:26] Hello and welcome to today's episode of the great birth rebellion podcast i'm your host dr melanie jackson and today i'm talking on the topic of shoulder dystocia but before i do i want to thank the sponsor of today's episode poppy child who is the creator of the birth box and the oxytocin bubble two tools that you can use to help navigate the pain sensations and events of labor as they arrive you can use that this tool the birth box and the oxytocin bubble to prepare through pregnancy uses a tool during birth and then also it helps you navigate the nervous system situations that might occur that might be a little bit buzzy and annoying during, parenthood poppy is offering great birth rebellion listeners 25 off the birth box and it includes the oxytocin bubble but you could also use the oxytocin bubble which is a, collection of music tracks and audio as a separate purchase if that's what you would like all the details are in the link in the show notes for how you can access the oxytocin bubble, or the birth box the other thing I would love to recommend to you if you haven't already found it in addition to all of this information that I offer you on the great birth rebellion podcast as you get ready for your Pregnancy, Birth and Parenting, I have a all facts, no fluff course or guide, online guide.
[1:51] On how to navigate the pain of labor without pain medication. So if you're keen to avoid an epidural and you want to maximize your chances of being able to work through the pain of labor without pharmaceutical medication and feel that incredible oxytocin high that comes from doing such a big and hard thing, the guide for giving birth without pain medication is what you're going to need to gather the tools and strategies to work through the pain of labor. The other thing that the guide to giving birth without pain medication has is a whole section, for your partner it's not too long as i said all facts no fluff and it's everything you'll both need it's only 47 and the best money you will ever spend on your labor and birth preparation all the details are in the show notes.
[2:40] All right, let's kick off on today's episode about shoulder dystocia. And I've been a private midwife for 18 years now. And today's topic is a situation, in birth that obviously I have to be prepared for because as a private midwife and mostly attending clients who give birth at home, I'm the one who has to deal with this emergency should it arrive. And I know I just said emergency, but what I do also want to say through this episode is that shoulder dystocia often elicits a lot of fear in women and their clinicians. But we have to remember, and if we reframe this in our mind, shoulder dystocia is a complication and it requires urgent attention, but it's not always an emergency. So just remember there's urgency, it's not always an emergency and that can help just calm the room in the event of a shoulder dystocia. So I call shoulder dystocia an urgent situation because it's usually resolved very quickly and easily and only becomes an emergency sometimes, not every time. Most of the time it is a manageable or preventable complication but it is an urgent situation. You can't wait and see with shoulder dystocia, your clinician or you as the woman or if you've got people there with you need to act if you believe a shoulder dystocia is coming or occurring.
[4:09] And as a private midwife, I know that I have a responsibility to be incredibly well prepared for shoulder dystocia and skilled in how not only to prevent them, but also manage them.
[4:20] And so my preparedness and experience and research is what I'm going to bring to this episode. And today I'm going to explain what shoulder dystocia is, what you can do to prevent it in the first place, and also speak to clinicians about effective techniques to manage shoulder dystocia, while doing, and here's the important part, the most effective techniques while doing the least damage to the baby. Because one of the things that can happen to the baby is when clinicians become overzealous or maybe a little bit adrenaline-fueled and anxious in the scenario of shoulder dystocia, that we do maneuvers that are too aggressive and too forceful and we can cause damage to the baby. So what I'm going to talk to you today is about how to do more gentle but effective, highly effective manoeuvres for shoulder dystocia whilst doing the least possible damage to the woman and the baby. And I've also got some research to share with you. As usual, all the research papers for this episode, along with all the other podcast episodes, are in the podcast resource folder. So if you're on the podcast mailing list for the Great Birth Rebellion podcast, you're.
[5:34] Every week, you'll get a link to the resource folder so that you can have a look at all of the research papers that I've used to make that week's episode and all previous ones. If you are not yet on the podcast mailing list and you want to be, and you want to get an email from me every Monday with all the juicy details and a heap of extra information, just sign up to the podcast mailing list. The link is in the show notes, or you can just go to melanethemidwife.com. But I've got a full list of the research papers that I've used for this episode, so I would encourage you if you're a clinician or if you're a woman who's highly invested or whoever you are listening today, and you want to learn more about shoulder dystocia and the management and the research behind it that podcast resource folder is where it's at, all right let's get going on shoulder dystocia to be honest.
[6:22] Shoulder dystocia is actually quite uncommon in my line of work, believe it or not. As a private midwife, the majority of my work is done at home. And a lot of the strategies that women use at home for labor and birth are all quite preventative for shoulder dystocia. So actually, in 18 years of clinical practice, I've only been a part of five or six situations where I've been the clinician managing the shoulder dystocia. Obviously I've been at other births as a second midwife and in hospital births and doing all these kinds of things and I've seen other shoulder dystocia scenarios playing out but for me personally five or six shoulder dystocia situations.
[7:01] But actually this checks out with how common it is because although there's a lot of fear around shoulder dystocia it's incredibly uncommon, and the stats on shoulder dystocia say that it occurs somewhere between 0.5% and 1.5% of births So only one or two per hundred births are complicated by shoulder dystocia. So although five or six shoulder dystocia situations doesn't sound like many, it's probably equivalent to how often they usually occur. But again, I assume would be less in my area of work, particularly though, because also obviously at home, women aren't having epidurals. They're usually not lying on their back. They're usually very active and we're also not doing inductions or vacuum or forceps. So there's a lot of preventative things that are happening to avoid shoulder dystocias at home. Now, over the years, I've sat in midwifery sessions with other experienced midwives and we've spoken in detail about the management of shoulder dystocia and by listening to each other's experiences and other clinicians and talking.
[8:12] Reading and courses and all these things, I've come to understand which techniques work almost all of the time. And in fact, which techniques you can actually skip over completely. So if you're new or a less experienced midwife and you feel like you either haven't had the opportunity to manage a shoulder dystocia or you're really scared.
[8:38] My suggestion is that you should start consuming information and understanding the theory of shoulder dystocia management. Seek out learning opportunities and then this theory is going to be at the fore of your mind so that when you are in the situation of managing a shoulder dystocia, that information can guide your practice. And I hope this podcast episode is part of your learning journey. But I will say even if you haven't had the opportunity to manage a number of shoulder dystocias, what you'll find is after the first few the penny drops you've already got midwifery skill you already have that talent and feeling your fingers and the knowledge in your head and the feelings in your heart on how to navigate birth with women, and when you start to work with shoulder dystocia and you see actually, how usually easy it is to resolve a shoulder dystocia that fear can melt away but you have to step in at first as a new midwife and take initiative to learn about this and practice and you will find that very quickly you will become confident with what it feels like to navigate shoulder dystocia with alongside a woman. The next thing I'll say to you especially early career midwives is that the one thing I've noticed as I speak with other midwives, is that the experienced ones have no interest in formulaic or systematic approaches to shoulder of dystocia management and instead they focus on understanding why and how each individual baby is stuck.
[10:07] And then by knowing that, they know how to get it out the way that that particular baby needs to get out. They navigate that situation based on the information there, not according to a rote learned formula or a step-by-step mnemonic. So if you've come today to learn about mnemonics and step-by-steps for shoulder dystocia, it's not happening here. I'm encouraging expert clinical reasoning as you navigate shoulder dystocia, not rote learning. So today I'm going to walk you through what I know of shoulder dystocia, what I've learned from other midwives, some of the research, how to identify and management, and also work you through some of the causes of shoulder dystocia and how to prevent it in the first place. But before I get into it, I want to speak directly to you midwives and keen obstetricians who are keen to learn from midwives. If you want to discover your full scope of midwifery skills, and you just heard then what I said about experienced midwives and if you want to get into the room with those midwives or you are one of those midwives yourselves and if you want to understand research and women's bodies and your role at pregnancy birth and postpartum and the physiology of that and how to work to the full scope of your midwifery practice, I'm opening up an opportunity for 200 clinicians, midwives or obstetricians.
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[12:15] It's not open yet just join the waiting list for the assembly of rebellious midwives the link is in the show notes and when it when enrollments open in October, 2026, you'll be the first.
[12:26] Okay, let's get into shoulder dystocia. I have delayed you long enough. Let's kick it off with a chat about what is shoulder dystocia. And I'll start by telling you that there is no clean textbook definition of anything in birth, but there's not even a clean textbook definition of shoulder dystocia either. The clean textbook version does everyone a disservice because it doesn't truly prepare you for the reality of shoulder dystocia. Specifically, if you look at definitions of shoulder dystocia, there's a lot of talk about the anterior shoulder and that's the shoulder that is underneath the woman's pubic bone. So if women who are pregnant, if you're imagining one of your baby's shoulders is wedged.
[13:14] This is often how shoulder dystocia is described. But the first thing I'll tell you is to stop obsessing about the anterior shoulder and assuming that it's the anterior shoulder. Any part of the baby's shoulders can get stuck on any part of the pelvis. It's not always on the pubic bone or the pelvic rim. So that's the first thing is we haven't got a really a clear definition of shoulder dystocia. So let go of that idea and just when you're trying to answer the question, is this baby stuck and is it stuck in a bony way, baby shoulder on the woman's bony pelvis, that's all the information you need is that the baby is stuck in a bony way, not a fleshy muscular way. And then what you're going to do next is start to apply some clinical reasoning and assessment to work at how and where the baby is stuck so that you know what to do next.
[14:12] So the next thing that you need to know is that the step-by-step rote learning that you did at uni or that you see in textbooks or maybe it's up on the wall of your workplace, the mnemonics, the helper mnemonic or the alarm mnemonic, I don't know, there's so many these days, that this type of way of looking at shoulder dystocia might actually slow you down and get in the way of managing it quickly. So while I was a student and a baby midwife, I learned all of the drills and the mnemonics and the steps and the timings, and now I've completely abandoned that when I realized that they don't serve you or the woman or the baby, which you'll discover as we go through this, that the mnemonics are not actually evidence-based, and I'll show you some of the research on that.
[15:02] But in real life scenarios, these mnemonics don't necessarily help you. So what I want to say first is don't assume it's always the anterior shoulder. And it doesn't matter how many mnemonics you've wrote, learnt, you are no closer to being prepared to managing shoulder dystocia if you're going to go back to that learning in the event of a shoulder dystocia. It doesn't apply in real life scenarios. You have to use clinical reasoning. And I'll start by talking about the stuck drawer analogy and remind you not to pull on a baby if you suspect shoulder dystocia. So if you're ever in the scenario of a shoulder dystocia I want the first thing that you ever think about to be do not pull on the baby, do not apply traction and the baby's head is not a handle. Those are the things that need to go through your head. If you're thinking oh man we are having a shoulder dystocia situation right here.
[16:00] Do not pull on the baby do not apply traction the baby's head is not a handle the next thing i want you to remember is that poor plastic spatula that is sticking up in your cutlery drawer that when you open it the spatula gets jammed up in the anterior part of the drawer or the woman anterior part of the woman's pelvis, and it prevents you from opening the drawer and in that scenario we all know that the solution is not to keep trying to pull out the drawer unless you're on your last nerve, what you would do is you would calmly close the drawer just enough, dislodge the spatula with your arm a little bit.
[16:41] Or maybe you just do a little slight shuffle of the drawer. Rearrange some of the things in the drawer and swipe the spatula down so it lays flat. So that when you open the drawer, the spatula is repositioned and nothing's getting stuck. Now the principle is the same with shoulder dystocia. If you just keep pulling that drawer out, you are going to bend and damage the spatula, aka the baby, if it comes out at all. And you will cause more damage, then if you just think for a second, calm down, don't try and keep pulling a stuck baby out in desperation. The strategy with the stuck drawer has never been to pull harder. No one ever says even just keep pulling that spatula will come dislodged. No. And this is the same too. If you're a skilled breech practitioner, we all get taught you disimpact the baby first before trying maneuvers. If a baby's stuck somewhere, pulling it through harder is not going to make it less stuck. It's going to make it more stuck. The same thing when you disimpact a breech baby, same thing with a stuck baby who's head down.
[17:49] And I'll talk through more of these strategies as we go. But the first point is don't pull the baby. You'll further impact it. You'll accentuate how stuck it is and you'll do damage to the baby. So going just back to my first point. The definition of shoulder dystocia is that it's often subjective. There's no objective measurement and it's actually the clinician, the person who's looking out for the mother and the baby.
[18:15] Who's put their hands on the baby and who's seeing what's happening and who has an intuition about these things and in consultation with the woman can actually work out if you're in a shoulder dystocia situation. The clinician there with the woman is the one who needs to put together all that complex information in their mind to determine if the baby's experience, the shoulder's social or not. And the women also have some incredible knowledge about what's happening inside them. And I'll talk to you about that too. And sometimes, even as a clinician when you're assessing things.
[18:50] You don't know until after the fact, until after you've tried a few things, if it actually was a shoulder dystocia. And putting hands on the baby can be part of the diagnostic process of working out, is this baby actually stuck? And this is why sometimes midwives or a doctor might act as if there's a shoulder dystocia. But then when they do try a few maneuvers, it turns out maybe the shoulders were just a little tight so midwives will say oh just tight shoulders, and so sometimes you might think it was shoulder dystocia but then and then you do something to prophylactically manage the situation and then when you step back afterwards with hindsight you actually know it wasn't I don't think it was a shoulder dystocia maybe I jumped in too soon but that's it's okay to act and do something if you think there's a shoulder dystocia, and then part way through realize actually I'm not in it that's far better than not doing anything, and the other important thing is to reiterate that to the women so if you've said to them I think maybe your baby's stuck I need to do something and you do something and it all resolves quite easily you think oh actually no that wasn't shoulder dystocia feed that back to the woman so that she can tell herself that as part of her birth story and that in her next birth she's not thinking, last time I had a shoulder dystocia is that going to happen to me again?
[20:12] And so saying something to her like, I thought maybe that there was a shoulder dystocia, so I did a few maneuvers and then partway through the maneuvers, it appeared as though, no, it wasn't a shoulder dystocia. So although yes, I put hands on your baby, you would have been able to give birth to this baby all on your own. And this is a story that the woman can tell herself going into her future births, that I'm capable of giving birth to a baby all on my own. Because the truth is, is that for women who have had a previous shoulder dystocia, they are at slightly increased risk of a shoulder dystocia again. And their clinician next time will ask them if there was any complicating factors with their birth. And if they say, actually, last time I had a shoulder dystocia, that could cloud the type of care they get next time. So it's okay to talk to the women about actually you did not have a shoulder dystocia that is not part of your story. So every shoulder dystocia is a unique and individual situation for each, every individual woman. And you might need to do something different to manage each one. But a true shoulder dystocia is a bony impaction, not flesh, not muscle getting in the way. It's not the perineum getting in the way. We do not do routine episiotomies for shoulder dystocias because the.
[21:32] It's a bony impaction. And so rotation of the baby and movement of the mother is the way to manage it. Not pulling harder, not being more forceful. It's moving the woman's pelvis and rotating the baby is how we navigate bony impaction. There are in some complex shoulder dystocia scenarios that some of the things that I'm going to mention today won't work. And in these situations the doctor has to break the spatula, aka the baby and intentionally damage the baby in order to get it out and sometimes that involves the collarbone sometimes that involves the baby's arm sometimes these are accidental injuries sometimes they are purposeful this is incredibly rare I've never seen it, most babies or spoons can be effectively repositioned to make it possible for them to navigate their mother's pelvis. And there's usually room in the pelvis. All you've got to do is rotate the baby to find the right space for the baby to move through.
[22:34] And what I was originally saying about shoulder dystocia diagnosis is that it can be subjective and, it's up to the clinician to decide if they'll step in and how soon, which leads me to my next point about the time interval between the birth of the head and the birth of the shoulders. So being an expert in physiological birth, that's really the main type of birth that I've seen. Some midwives are used to seeing highly complex and high intervention births all the time and they're always saying, oh I wish I could see physiological birth. My workload is the opposite. I am mostly witnessing normal physiological birth and in a normal birth, The birth of the head happens, usually in one contraction. Sometimes the whole baby comes out in one contraction, also normal, also fine. But normally the head comes out and is born and it's not unusual to then have to wait for the next contraction in order for the shoulders to be born in the next contraction and the rest of the baby. So I'm familiar and comfortable with waiting for the head to be born, waiting for the next contraction for the shoulders and the rest of the baby.
[23:47] For midwives who are not, or obstetricians who are not familiar with this, it can be an uncomfortable time of waiting if it's not your usual practice and if it's not what you've usually seen. Because it means you're waiting that whole gap between contractions for the rest of the baby to be born and it can feel like a really long time. And you may be thinking, oh my gosh, is it not coming because there's shoulder dystocia. But there are things that you can be checking in that gap to determine if the baby is not coming just because that's the normal physiological way of birth, or is there shoulder dystocia happening? Is the baby stuck? So let's talk about the signs of shoulder dystocia and if this might be happening during that gap.
[24:35] And some of the research, again, that you'll see in the podcast resource folder, talks about this really tiny window of 60 seconds between the birth of the head and the emergence of the shoulders, that this is somehow some standard of normal.
[24:53] And if there's a longer interval than 60 seconds, that you might start to suspect shoulder dystocia. But my guess is that this has come from somebody or a research team or a clinician, or I don't know where it came from, but, that it's come from somewhere that doesn't understand physiological birth because 60 seconds is a terribly short interval between the birth of the head and the birth of the rest of the baby in a normal physiological birth. And I'm not sure what the current practice is in hospitals anymore, but at home, what I've learned through watching birth and also from colleagues and what I do in practice is that if the head comes in one contraction, and there's no delay in the full head being born during that one contraction. We'll talk about that. It's considered completely appropriate to wait for the next contraction before the rest of the baby is born. But it would be different if the baby's head was born and then you saw signs of shoulder dystocia. So there's some clinical reasoning that goes on. I don't just sit there and wait and I go, wow, the baby's having shoulder dystocia. I'll wait for the next contraction. And actually this has been written about. It's called the two-step method for having a baby. And I did not realize that there was a name for just waiting for the shoulders to come in the next contraption. But it's called the two-step method.
[26:15] Okay. It's just normal physiological birth, but it happens in two steps. They had to name it because people are working sometimes in birth trying to get the baby out in one step.
[26:26] This time interval between head being born and shoulders being born, there's this research paper. It was done in 2022. It's called Shoulder Dystocia and the Range of Head-Body Delivery Interval, HBDI, the association between prolonged head-body delivery interval and neonatal outcomes. And it's, again, in the resource folder if you want to have a read. But this 2022 paper explains that a two-step approach to waiting for the baby to be born allows the baby time to move through its mother's pelvis without interruption. The first step being the birth of the head and then the head restitutes, what we call restitution, and the shoulders position themselves.
[27:10] During the gap. And in the next contraction, the rest of the baby is born with the attendant not interrupting. That's considered the two-step process of birth. And this article suspects that this two-step approach, where they just wait for the baby to be born rather than forcing it, would actually reduce the rates of shoulder dystocia. Because when you do the one-step method, the clinician doesn't allow the baby to be born in two steps and instead applies their hands and does downward traction and maneuvers to get the baby out all in one go without allowing them to take the steps themselves to get themselves out. And that interrupts the baby navigating the pelvis. And it could actually increase the chance that the baby will get stuck or have a shoulder dystocia because it's in the gap after the baby's head is born that it repositions its shoulders and gets ready and in an ideal position to be born next. And that's signaled by restitution of the baby's head. When we see a baby restitute after the birth of the baby's head, we know that that means the shoulders have navigated the pelvis and we are less likely to be experiencing a shoulder dystocia situation.
[28:23] So this 2022 paper is suggesting that we should be moving towards a two-step practice and be comfortable with the baby's head being born and waiting for the shoulders. And you've got to sit with that discomfort and realize that the gap between the contractions between the head and the rest of the baby is the one where the baby is maneuvering its own shoulders through the pelvis.
[28:46] And so as midwives, the head comes out, we see the restitution of the baby in a normal and uncomplicated birth, and we can see a successful restitution because the baby's head, rotates to look more towards its mother's bum cheek than her anus, if I had to describe it. They wriggle their shoulders, they can turn their head, they're usually grimacing, and there's some movement of the baby. And if they do all these things, then it's okay to wait for the next contraction. Okay, so now hold that thought for a second. The head has just been born and it's restituted and we're waiting for the next contraction for the shoulders to emerge. But let's step back a little bit and have a think about some of the predictive signs that maybe a shoulder dystocia is happening that you can observe with the birth of the baby's head. And then we'll move on to shoulder birth in a second.
[29:45] Now, the first possible sign that a shoulder dystocia could be happening is that the baby's head is born slow and gradually. So a slow, gradual birth of the baby's head, where the whole head is not completely born to under the chin after the whole birth of its head, a shoulder dystocia is not definitely happening, but this is sort of your first red flag. So slow gradual birth of the baby's head after crowning is your first sign that the baby might be having trouble navigating its mother's pelvis, and I've been at births where the woman is crowned and then the head starts coming and that in one contraction the baby's born to its eyes and then the next contraction the baby's like born to its lips and it's kind of trapped in its mother's perineum to its lips, and then in the next contraction the baby comes out but the chin is not quite all completely born and you're kind of wanting to sweep the chin out from under the perineum, and during that time the midwives in the room are looking at each other without words and knowing that in if in the next contraction if that baby doesn't restitute or in the next contraction they don't see shoulders start coming someone needs to do something and in fact after seeing that But for me, personally, if that happened and we go eyes, lips.
[31:10] The head is born but the chin is still tucked in a little bit, which I'll talk to you about later.
[31:17] To me, this would be the time at home. Usually a lot of my clients choose to have water births. So if the woman was in the pool, I'd be asking her to get out of the pool for two reasons. So if I saw that, a slow birth of the head over a number of contractions, I would be asking her to get out of the pool. And the two reasons are, is that if I do need to do shoulder maneuvers, they are easier to do with the woman on hands and knees and me kneeling behind her so that I can get in a good position and a good grip on the baby.
[31:48] Secondly, the movement of the woman just getting out of the pool can be enough to create enough change in her pelvis and dislodge the baby before I even need to do anything. But if she is on land, I would be suggesting that she gets into some kind of exaggerated lunge position. We sometimes call this a runner's start position or get one leg up or knee up high onto something like a couch or a stool or some kind of deep squat position, or even just a few big deep squats like squatting down and then standing up and squatting down, which if you're a midwife you'll know also that one of the maneuvers the McRoberts maneuver is done by a woman, lying on her back and bringing her knees up to her boobs so getting her in actually an upright squatting position is not dissimilar to a McRoberts position except that her pelvis and tailbone are free to move because she's not obstructed by the bed. So those are your first initial signs of shoulder dystocia that there's this slow gradual birth of the baby's head as if it's working really hard just to get its head born and, the head is not fully born up past the chin.
[33:02] And this, I'll talk to you about a little bit later, but that's called a turtle sign. And if, you know, if it looks as though the chin is trying to emerge back up and the baby's trying to go back up into its mother's vagina, that's probably because its neck and head are incredibly extended while its shoulders are stuck back on the maternal pelvis. And actually the head is trying to reunite itself with the shoulders. Okay, so those are some first signs. Then next, if after the head is born, there is no restitution, the head does not do its little turny thing, then you need to start thinking about your next steps because now you've already got two signs of a possible shoulder dystocia because you've got the turtle sign. Failure to restitute can be a sign that the baby's going to need help to get out in the next contraction. And if no restitution, this might mean the shoulders have not repositioned themselves. And if a lack of restitution is paired with a turtle sign and a slow delayed birth of the baby's head now you've got a collection of reasons to believe that the baby is having trouble traversing its mother's pelvis.
[34:11] But again, we're going to go back again a little. So we've already spoken about moving away from this thought that the baby should come out in one contraction. And if it doesn't, that we start to suspect shoulder dystocia. But that's going to lead to an overreaction in clinicians. And we've got that 2022 study that showed that although with the two-step technique, the time interval between the birth of the head and the birth of the shoulders, is longer actually by doing the two-step method you can reduce the rates of shoulder dystocia by letting the shoulders maneuver themselves through the pelvis, instead of expecting the baby to comply to some 60 second window to get itself born.
[34:54] And we've already looked at the few signs a few signs of shoulder dystocia just from the birth of the head and explained a few of the early strategies like position changes and suggesting the two-step method that you can use to help the baby to navigate its mother's pelvis before you even need to put your hands on the baby. Those are a few things that we've already worked out. And another thing that you can help to prevent shoulder dystocia is when the woman is giving birth in positions that allow her to move and where she's more upright and supported because a woman's pelvis is mobile during labor and birth. It's movable and it's designed to be that way because the baby has to get through there. It's the movability and the malleability of the woman's pelvis is in response to the baby and the birth process and also the hormones of pregnancy and labor and birth make it so that it's more movable.
[35:53] But if anything, like the bed or an epidural or being up in stirrups is preventing her from moving, the woman's pelvis, your pelvis, if you're listening as a woman, is stagnant and still. And this will increase the chances of a shoulder dystocia. And I've heard this situation being referred to as bed dystocia. And it just harks to the knowledge that labor and birth is a dynamic process where the baby needs to move through its mother's pelvis, and that also when the woman moves, that helps the baby to navigate her pelvis. So if the woman is completely stagnant, stuck flat on a bed, and there's things that are impacting the way her pelvis can move, then this is also going to increase the chance of shoulder dystocia. And certainly one of the shoulder dystocia management tools that clinicians are taught to use if there is a shoulder dystocia is actually to ask the woman to turn over to her hands and knees if she's laying on her back. That is one of the strategies. They say if there's a shoulder dystocia happening, turn the woman over. And this not only allows the clinician easier access to help the baby, but it also allows the woman's pelvis to move, and the act of getting onto your hands and knees, just like the act of a woman getting out of the pool, the act of getting onto her hands and knees could be enough to dislodge the baby or help the baby's shoulders navigate her pelvis.
[37:19] And the other thing we have to acknowledge is that given the opportunity, women will instinctually change position and create change in their own pelvis because they can feel if something is stuck. They can change the way the baby moves in and through their pelvis by some maneuvers that they do themselves. And we might all be unaware that there could have been a potential shoulder dystocia and the woman's movements can be effective in helping the baby move through. So it's okay firstly to let the baby's head be born and then wait for the next contraction because that's how physiology works and sometimes the.
[37:58] But then it's also okay to see what a woman will do. She might do some fancy footwork in between those two contractions based on her own sensations to help the baby move through her pelvis. And if we can do less and allow the woman and the baby to do more, this is going to be the least impactful on the baby and on the woman. We only need to intervene in these situations when it's absolutely necessary.
[38:25] All right, now I'm going to cover a few other causes of shoulder dystocia. So how do the shoulders get stuck on the bony pelvis? And here I encourage you to have a look. If you haven't already heard of it, there's a podcast episode that I recorded called Big Babies, Small Babies, and it talks about the size of your baby and how that can be diagnosed. What we learned in that episode is that diagnosis of larger babies is a lot more difficult than diagnosing smaller babies. However, larger babies seem to be at more risk of shoulder dystocia. So if you believe or if you've been told that you're growing a bigger baby, I would listen to that episode first. It's a nice companion to this episode on shoulder dystocia. And the reason I say that is, as I said, statistically speaking, a baby bigger than four kilos statistically has more of a chance of a shoulder dystocia than smaller babies. And again, in that big baby, small babies episode, we talk about the reasons your baby might be bigger. Sometimes babies are bigger. Most of the time babies are bigger just because they are able to fit through your pelvis. But sometimes babies are bigger due to pathologies like gestational diabetes or highly processed diets causing bigger babies than they should be. But if we're going to be starting to sort of try and create a little bit of a risk profile for who might be at more risk of shoulder dystocia than bigger babies or if you've had a previous incidence of shoulder dystocia, you have a higher incidence of that in following births.
[39:55] But this is also possibly related to the fact that typically each baby you have gets statistically bigger each time. Not for everybody, just saying, if you plot them along a chart, generally speaking on a population level. And so we actually see more shoulder dystocias in women who have had babies before than first time mums. So that's another risk factor. Unfortunately, the more babies you have, your risk of shoulder dystocia seems to go up. But nonetheless we know some of the risk factors but there is no prediction tool it's a largely.
[40:31] Unpredictable situation and these are just some of the things that might put up a red flag, now I know all these things might sound a little scary that maybe the risk factors could be stacking up for you but just remember your pelvis is designed to let babies come through we are made for this. The bones in your pelvic structure, the ligaments, tendons, everything through labor has been prepared through pregnancy and your pelvis is movable and flexible. It's important to remember that your pelvis is not a fixed structure. It's something that opens and moves. And then when all those hormones are added through the impact of pregnancy, we aid that process even more.
[41:15] And I just want to say here that there have been a growing number of women who have been telling me that their physiotherapist or their doctor have told them that their pelvis is too small or not suitable for vaginal birth, that their baby won't come out or that their baby might get stuck and they should plan a preventative cesarean section. And I just need to tell you that if you've been told that it is time to get a second opinion because there is no way that anyone can tell the internal capacity of your pelvis or how it will move and function during neighboring birth. There is not a single way that we can measure if your baby will fit out of your pelvis. We can't do that. So if someone tells you the baby won't come out, you need a cesarean section, it's time to get a second opinion. It's highly unlikely that your pelvis cannot allow a baby out.
[42:11] So just to summarize, though, review the possible risk factors for shoulder dystocia. If you've had a previous one before, if your baby's over four kilos, if your baby has been born by vacuum or forceps, if you've got an epidural or you're laying flat on the bed or if you're in stirrups, and the final one is an induction. So an induction of labor creates statistically higher chance of shoulder dystocia. And what that's thought to be related to well partly is that the contractions that you get during an induction are a significantly different sensation and, different impact to the ones that your body would normally offer you, and so it's not surprising that more women who have inductions also choose to have an epidural and when you combine those things you increase the risk of shoulder to shoulder dystocia, but the contractions that you get with an induction are stronger and more frequent than what your body would be giving you. In fact, Dr. Sarah Buckley, who has done a stack of research on oxytocin and induction.
[43:11] In 2023, wrote a paper and showed that during an adduction, maternal oxytocin levels are two to three times higher than physiological labor, which creates exaggerated labor contractions that don't mimic physiological labor. And so there's this thought that the babies are being sort of forcibly plugged into the pelvis too forcibly, unnaturally forcibly.
[43:33] In a way that they're getting impacted because of the length, strength, and frequency of these contractions. So it's, of course, multifactorial, but you can see why an induction might increase the risk of shoulder dystocia because it also increases the need for forceps and vacuum because the physiological process has been interrupted. So we have to expect there's going to be some roll-on effects from that. Now, as we're talking about this idea of cesarean sections, and often clinicians are using inductions for bigger babies for the specific reason of preventing shoulder dystocia without realizing that actually by offering induction, they might be increasing the risk of shoulder dystocia.
[44:12] But there is some thought in the research of how do we prevent shoulder dystocia? So at the extreme end, they are offering women with bigger babies, cesarean sections or inductions to prevent their babies from getting any bigger, to reduce the chances of shoulder dystocia. But these are two non-evidence-based strategies for the prevention of shoulder dystocia. There is no prediction tool for who is more likely to have shoulder dystocia and who's not. Therefore, we can't make clinical decisions based on the possibility that a woman will have a shoulder dystocia just because there are some risk factors. There's no way to predict shoulder dystocia. So we can't make clinical decisions, based on flawed predictive tools. Nothing exists. We haven't been out. It's an unpredictable circumstance. All right. So those are some of the causes and preventative measures, some of the diagnostic criteria or ways to identify shoulder dystocia.
[45:11] But now let's talk about, and because we got up to the point of, okay, the baby's head is born and we're starting to suspect shoulder dystocia.
[45:20] Let's have a look at actually what to do in a situation where the baby's head is out and you believe that a shoulder dystocia is happening and the shoulders have not traversed the pelvis. And I know this is what all the midwives and clinicians have come to hear. How do we resolve shoulder dystocia after we've identified one? How do we resolve it? So we already spoke about the real possibility that if we just wait for the next contraction, that it's quite possible the baby will sort itself out and the woman can create some movement to resolve a potential shoulder dystocia herself. So if we can encourage you to get comfortable with waiting for that next contraction and also encouraging the woman to move if she feels like she needs to during there. And obviously there's some nuance here because a skilled clinician can look at the baby after the head comes out and immediately know that they need to act or if they can hang back and wait a little bit. And also listen to the woman. If she's trying to tell you something, she might call out like something's wrong or get it out or it feels stuck or something's not right or I can't push the baby out. In which case, I would just take her word for it. This is information that she's got that you don't have and in that circumstance, you should just act. But before I go further into any actual maneuvers.
[46:42] Can I just encourage you midwives, clinicians, obstetricians, if you're listening, if your midwifery sense of your obstetric sense is pinging and telling you to do something or that something's not right, it's okay to just honor and act on that. Your brain has put something together that maybe you've not been able to quantify yourself and I've definitely done it, just trusted my instincts and, So much so that I've explained to the woman afterwards is that I can't explain why I felt like I needed to do that. But my instinct, my midwifery instinct told me I couldn't put my finger on it. And so I decided to do it based just on maternal midwifery instinct. And I have no shame in explaining that to the woman that my intuition was part of the decision-making process and I went for it. So it's okay if you're looking and thinking, oh, I just feel like I need to do something, but I can't explain why. Do it. You're a midwife. you've got some internal intuitive midwifery knowledge that you can rely on. Okay so talk about the clinical strategies for shoulder dystocia.
[47:42] So let's assume that you have confirmed that there is definitely a shoulder dystocia. You've got a feeling about it, the signs are stacking up, perhaps you put your hands on the baby and you felt a little bit and it just doesn't seem like the baby will come in the next contraction without your help.
[47:58] All right so you've got what you suspect is shoulder dystocia. The first thing, and I want to encourage you, especially as well if you're a student midwife and you've been taught, or if you're a midwife anywhere, and you're learning about shoulder dystocia and you've learned the mnemonics, like the helper mnemonic, there's these different mnemonics that midwives are given to remember the steps to resolving shoulder dystocia. I'm going to suggest that these mnemonics are incredibly unhelpful when you're actually in the moment of having a shoulder dystocia because they interrupt your clinical reasoning. They interrupt you being able to look and see what's actually happening to this particular baby. What position is the baby in? What position are the shoulders in? What do I need to do to release it? Sometimes these mnemonics don't consider individual elements of this woman's labor and they create robotic care. But what is required is for you to look at the situation, use your hands, use your eyes, use your knowledge to understand why and how this individual baby stuck and when you know that you'll understand what you need to do to get it out.
[49:03] So the first step is a quick and thorough assessment of the baby, its position and how it's stuck. Women aren't robots. They are not machines. They're not made exactly the same. You cannot apply routine care to every emergency situation or any labor and birth situation. You need to use clinical reasoning. Not all babies are the same. They're not all stuck the same and not all women's pelvises are the same. So actually look what is in front of you. When shoulder dystocia happens, you're just presented with this problem that you need to solve. And there are various manoeuvres that you can use to solve the problems, but how and which ones you decide to use is up to you and it's up to your clinical reasoning. It's okay to skip over some if you feel like they're not clinically appropriate or hone in on particular ones that you believe are indicated in this particular situation. So I'm not saying abandon some maneuvers or mnemonics that we were taught. I'm just saying don't get hung up on doing it step by step and hung up on how long you've been trying each one and which one's second, which one's third, and what you should be doing next.
[50:15] But the first thing that I would do is just throw out the mnemonic for a minute. First thing I would do is change the woman's position in order to.
[50:25] Help her pelvis move or flip her over. And I know in many of the sort of hospital-based education programs that are offered for shoulder dystocia, the option to flip the woman over, that maneuver, I'm doing inverted commas, maneuver, is usually the last consideration. But I'm suggesting that you moving the woman to a hands and knees position or, out of the pool or into a different position should be the first consideration because that will move her pelvis. And if the baby is stuck up on the pelvis might help dislodge it. So it makes sense to try and move a pelvis at the same time as trying to move the baby because it's a bony impaction. They're stuck together. And if you move one or the other, you could dislodge the baby.
[51:15] So for me, most of my clients are in the pool. The first thing I do is, hey, I think it's time to get out of the pool. And just the movement of flinging their leg over the side of the pool is enough to disload the baby or leaning forward or deep squat, as I said before, the running start. But getting the woman onto her hands and knees and actually accessing the woman from being behind her instead of over the top of her is an incredibly, advantageous position to be in for the clinician in terms of the most effective management strategies.
[51:47] And a deep squat, so another thing that I've seen a midwife do is there are a woman standing up and she gets her to do sort of a deep squat and then stand up again and then another deep squat and stand up again and then change position again. Again, it's all about dynamic movement of the pelvis to try and dislodge the baby in the most gentle way possible so that the baby's not damaged. And this is why clinicians use McRoberts. So the McRoberts position is something that's in a lot of the mnemonics and requires, you taking the knees up to the woman's nipples to make the pelvic outlet a different size. They say it makes the pelvic outlet bigger or the pelvic inlet bigger. So then we've already started, we've changed the woman's position, we're working out if that's going to work, see if there's any movement, does it look like the baby's becoming dislodged. Then, and here's something that's actually not in many of the mnemonics, but many clinicians will do. And I'm harking back to the recommendations I made at the beginning of the podcast episode of do not pull on the baby. Downward traction is not a treatment strategy. It's part of diagnostics, but you shouldn't do it too much. The baby's head is not a handle.
[52:58] But what you might witness is clinicians putting downward traction on the baby's head. So if the woman's lying on her back, that will mean that the clinician is going to push the baby's head down towards the woman's anus, towards her bottom, to try and release the anterior shoulder that is stuck up on the pelvic rim at the front, on like her pubic bone. Again, can't always assume that the baby is stuck on the anterior rim. That was another thing I mentioned earlier. But you've got to remember the stuck draw analogy. This is why I have a problem with the idea of putting downward traction and putting pressure and trying to pull the baby as a maneuver. If you use that one and people often use it in combination with McRoberts so they'll bring the woman's knees up high to her nipples they'll tell it a push, and then the clinician is putting traction on the baby's head or trying to pull the baby's head from the outside and we can we know from the stuck drawer analogy that this is only going to compound the issue and babies are, mostly pretty robust but this is a maneuver that causes damage to the baby.
[54:07] And I believe that there are far less invasive and traumatic ways to get a baby out. And I do feel that encouraging a woman to move herself, into a more upright position or squatting or hands and knees positions is far less aggressive than the McRoberts, which actually also requires two people to help, the woman bring her knees to her nipples. It requires the woman to be lying back with people over the top of her. And then there's a clinician who's navigating the baby. And so it's an incredibly vulnerable and kind of high adrenaline situation to have that many people over you. And upright positions or forward-leaning positions are less vulnerable. The woman is actually not exposed to what's happening in the room and the woman has more control. This just makes more physical sense to me, not only for the experience of shoulder dystocia but it makes physical sense, to have the woman off the bed and not trying to help the baby navigate the pelvis.
[55:17] And a quick note here, it might be not so quick because I want to refer to some research, but the helper mnemonic, which is one of the mnemonics that we're taught to use for shoulder dystocia, helper, which I don't recommend, it also assess, it suggests evaluating for an episiotomy. I would completely skip this part. Don't evaluate for episiotomy. Don't think, oh, should I do an episiotomy in this situation? Just focus on working out how the baby is stuck and what you need to do to get it out. Forget episiotomy. Do not waste your time with an episiotomy. The other one I would suggest completely skipping is suprapubic pressure. Honestly, that maneuver just feels so violent. And although it's an external maneuver, it's so invasive to the woman. And if McRoberts or repositioning didn't work, like move to the posterior arm. What are we doing externally trying to work this out, putting pressure on the woman's pubic bone? Although it's not internal, it's quite invasive. And putting traction on a baby causes damage to the baby. So why not move to the posterior arm? And of course, they're internal maneuvers. And we'll talk about how to get consent for those and how to inform the woman of what's happening and see if she objects or not.
[56:40] But there was some research done, quite a large study actually, about the effectiveness of the McRoberts manoeuvre. And I'm putting this here because I know through this episode, I've talked about almost doing away with the shoulder dystocia mnemonics.
[56:57] And there's evidence for why I believe that, not just in practice, but what I've learned from other midwives, but in actual research. And in this study from 2007, it's called Management of Shoulder Dystocia, Trends in incident and maternal and neonatal morbidity. It's in the resource folder. You can read it. But there were 514 cases of shoulder dystocia among nearly 80,000 births. So that translates to a 0.6% shoulder dystocia rate, which is what I told you about 0.5 to 1.5% is the amount of births that will end up having shoulder dystocia. So this study was 0.6%. And over that study, the McRoberts maneuver was used increasingly to overcome obstruction of the obstruction of shoulder dystocia. So it started at 3%. The use of McRoberts started at 3% during the first five years. And over the next five years.
[57:55] It was used in 91% of the shoulder dystocia cases. And the incidence of shoulder dystocia, the brachial plexus injuries, which is one of those injuries that you can cause by pulling too hard on a baby, neonatal asphyxia, so low oxygen of a baby, all increased over the study period without a change in maternal morbidity frequency. So the explanation for the increase in shoulder dystocia was unclear, but the introduction of the McRoberts maneuver has not improved outcomes compared with earlier results is what they concluded. So these authors says so we do have to ask some questions about the effectiveness of some of the existing methods and if they even work. So that's some research about McRoberts is that although the use of it increased it didn't decrease it didn't it wasn't any more effective than before they started using McRoberts.
[58:54] Now, there is some compelling evidence that turning a woman onto her hands and knees is an effective strategy. So there is a 1998 paper called All Fools Maneuver for Reducing Shoulder Dystocia During Labor, which looked at the outcomes of 82 shoulder dystocia cases. And in this study, the incidence of shoulder dystocia was 1.8% and half of the newborns that experienced shoulder dystocia were over 4 kilos, and that was a risk factor that I spoke about earlier. In the shoulder dystocia situations, after putting the woman on hands and knees, 68 women, so 83% of the women who had shoulder dystocia, 68 of them, gave birth without the need for any additional manoeuvres. Turning her on her hands and knees was enough to resolve 83% of the shoulder dystocia situations. Okay. They also talked about.
[59:50] The head-to-shoulder timing between was about 2.3 minutes, plus or minus a minute, but the average was 2.3 minutes between the birth of the head and the shoulders. In this study, there was no maternal or perinatal mortality, so no one died. Morbidities, so injuries, were noted in four of the births. There was one postpartum hemorrhage that didn't require any major treatment. it was resolved easily. One baby had a fractured humerus arm, which is their arm bone, and three had low APGAS scores. And all of the morbidity, so the injuries occurred in babies who were over 4.5 kilos. Again, it's the bigger baby thing. But again, not a huge, not a huge percentage. So what we've got here is some evidence that McRoberts actually hasn't created a change in shoulder dystocia statistics, even when they use it pre-preventatively. So this is what some people do. They go, oh, we're a bit worried she might have a shoulder dystocia so she can give birth in a McRoberts position, but that didn't seem to help. Alternatively, there's some evidence that turning a woman onto her hands and knees could be effective.
[1:01:08] So there was this other more recent study about this technique of hands and knees, and they compared the hands and knees maneuver to McRoberts to see which one was better. Did one outperform the other? Let's have a look. Before I talk to you about this study, a note about this hands and knees position, and where it originated. So there is a midwife called Anna Mae Gaskin. She's an American midwife, and she traveled to Central America and learned from Guatemalan midwives. And what she observed at some of the births that they were at was this maneuver where they would turn the woman over onto her hands and knees to help resolve shoulder dystocia. So while she was there with them, they spoke with her about this technique that they were using, these traditional midwives were using, to help with resolving shoulder dystocia. Ina May Gaskin brought that back and used it in her clinical practice and introduced it to the rest of the world, whereas previously that knowledge had been held by the traditional midwives.
[1:02:14] As a result, that maneuver, the hands and knees maneuver, was named the Gaskin maneuver. So if you see it on mnemonics or in some research articles or you hear about the Gaskin maneuver, that maneuver was named after Ina May Gaskin. And that is upsetting to some people because some people will say that Anna Mae sort of stole that information from the traditional midwives and claimed it as her own. My experience with this situation is actually every time I've heard Anna Mae talk about it or write about it, she always explains where she got it from. That it wasn't an original idea of hers, that she learned it from some traditional midwives and that manoeuvre was named after her.
[1:03:00] In one hand, I absolutely understand that some people feel like this was some kind of knowledge theft. However, if Ina May hadn't brought that back, we may never know. And she always acknowledges that she got it from these Guatemalan midwives who held that knowledge before her. And so now we know that hands and knees, because of the knowledge of those traditional midwives, is a technique that we can use to help navigate shoulder dystocia. And in a world where most parts of the woman's body and medical techniques and parts of pregnancy and birth are named after men, I think it can be celebrated that this has been named after a woman and a midwife and that it was traditional midwifery knowledge that has worked its way into modern midwifery practice. And I think this is a situation to be celebrated.
[1:03:55] And acknowledge the roots of this knowledge and how it was translated into our care today. So this study that was published in 2021 called Cohort Study of the Use of Hands and Knees Positions as a First Approach to Resolving Shoulder Dystocia and Preventing Neonatal Trauma. This study compared the use of McRoberts positions compared to the gasket manoeuvre, the hands and knees position. And I'll read from the paper for you.
[1:04:23] So they say that the McRoberts Maneuver has become the dominant method for resolving shoulder dystocia. But another method that is less commonly used is the Gaskin Maneuver, which was first described by the midwife Anna Mae Gaskin, who learned it from traditional midwives in Central America. And it involves turning women onto their hands and knees as a position to navigate shoulder dystocia. They refer to one retrospective study that reported an 84% higher resolution of shoulder dystocia and less injury to the baby with the use of hands and knees position as a first approach to resolving shoulder dystocia, which is the one I just talked to you about, the 1998 study. So the hands and knees position was reported to result in a wider pelvic diameter with the supine position and therefore facilitate rotation of the baby and the birth and the possibility of resolving shoulder dystocia just by doing that manoeuvre. So the purpose of this study was to explore whether applying the Gaskin manoeuvre as a first approach.
[1:05:27] Is safer and better than applying the McRoberts manoeuvre as a first approach. So what did they do? The time series cohort study was conducted in a maternal, child health hospital in China over a seven-year period. Between 2021 and 2013, all women receiving support during birth were enrolled in the control group. So during this period, when shoulder dystocia was suspected, so for the first two years, If shoulder dystocia was suspected, the McRoberts Maneuver was used, and that's the one that's described in the helper mnemonic. Then, between 2013 and 2017, there was a complete change in practice that was implemented for all vaginal births at that hospital, and midwives were instructed to use the Gaskin Maneuver, instead of the McRoberts Maneuver as a first protocol, if shoulder dystocia was suspected. So all of the women between 2013 and 2017 were now receiving the Gaskin Maneuver instead of McRoberts as a first-line treatment or management strategy or preventative strategy for shoulder dystocia if it was suspected. Then they had a look at the outcomes. Let's have a look. So.
[1:06:46] Injuries in the control group, so the McRoberts group were the control group. The injuries in the control group including 14 fractures, clavicular fractures, which is the collarbone, one permanent brachial plexus injury, three temporary arm movement disorders that resolved within seven days. In the experiment group, so the experiment group was the Gaskin Maneuver group, there was 58 cases of shoulder dystocia. In this group, the Gascar Maneuver group, there was only one case of clavicular, fracture compared to 14. Three temporary arm movement disorders, which resolved within three days. So in the first group, there were also three, but they resolved in seven days. And no permanent brachial plexus injuries compared to one in the other group. Now, what they found is that the rate of baby injury in the control group, in the McRoberts group, was 14.6%. But in the experiment group, the Gaskin Maneuver group, it was 1.7%.
[1:07:52] And that's a massive statistical difference. The authors of this study concluded that resolving shoulder dystocia by turning to the Gaskin maneuver as a French approach reduces the incidence of baby injury when compared to the McRoberts maneuver. And that this method should be recommended in clinical practice for better neonate outcomes. So we've compared McRoberts to the Gaskin maneuver. And it turns out the Gaskin maneuver is a clear winner. and we need to stop putting it at the end of the mnemonic and the end of our strategies, start putting it at the beginning. So, so far I've suggested movement to open up the pelvis, the Gaskin maneuver being far more effective than the McRoberts, and getting the woman into a position where you actually can access the posterior space of her pelvis rather than being in front of her with her on her back where you're more likely to be able to access Just the external parts and the anterior parts, but not the posterior parts.
[1:08:54] And this will prevent you from impacting the anterior shoulder further down. And the other thing that I really keep pushing here is do not pull on the baby because this will further impact the problem. And don't use the baby's head as a handle. I've seen, I know I keep saying it, but I have seen experienced doctors who.
[1:09:16] Grip and pull under the baby's chin and, like use the chin as some kind of anchor point to pull the rest of the baby out just have that in your head the aim is not to pull you want to open up the woman's pelvis create movements and then the next, thing to do and also this is not just me saying it I've spoken to other midwives about shoulder dystocia management but the vast majority have abandoned all other techniques and instead use maneuvers that take advantage of the posterior space of the woman's pelvis. So if you've already heard me talk about movement, the Gaskin maneuver, and not pulling on the baby, the next thing that you need to embed into your mind is how incredibly spacious the posterior part of a woman's pelvis is. So much of what we're taught about shoulder distocial maneuvers focus on the anterior parts of the woman's body. But although we've been encouraged to focus on the anterior part of dislodging the baby we've forgotten the massive amount of space in the posterior part of a woman's pelvis that we're not using, and the baby's not even you need to get through so, if you've flipped the woman over and now the baby's looking at you because, it's in an anterior position.
[1:10:38] I personally favor internal maneuvers for shoulder dystocia over the external ones. And I'll tell you why, because everyone's going, what? Why is it less invasive to put your fingers in a woman's vagina? These internal maneuvers are usually called second line management strategies. Like don't use these until you've already done the external ones. But my belief is that the external ones are actually more aggressive and more damaging to both the woman and the baby. And I think the internal manoeuvres are more gentle on the baby and they're more invasive in a sense that you do need to enter into the woman's vagina in order to do them. However, my feeling is that that is still less invasive than the external manoeuvres and less traumatic. I mean, that's a whole discussion to have.
[1:11:31] When I'm in a situation of shoulder dystocia, it's hands and knees, access the posterior space, rotation of the posterior arm and removing the posterior arm before anything else. And this just always works. And I've spoken to so many midwives who say the same. Keep it simple. Women on hands and knees and then access the posterior space. Rotate instead of pull on the baby and access that posterior space to sweep out the posterior arms, stop focusing on the anterior space. And midwives just always say that it works. So once the woman is on hands and knees, your next thing to do is to find the posterior shoulder. So this is the one that would be most near to the woman's coccyx. So she's on hands and knees and you are entering from the posterior space. Don't try and access the woman's pelvis from the anterior space. You'll freak out because there's no space there. There's heaps of space in the posterior part and the woman's on hands and knees. So you can easily access that posterior part now. So it's easy to find that when the woman's on the hands and knees and the easiest way to do it without having to do too much mental gymnastics about which position is the baby in because you do want to know what position the baby's in when you're trying to navigate shoulder dystocia.
[1:12:56] But if you find the top of the baby's head which is already out and then, follow track your fingers along the baby's head and trace it up your fingers will enter into the woman's vagina And as you seek to find the baby's back, once you found the baby's back, sweep your hand, up and across.
[1:13:20] Into the posterior space until you meet the armpit of the baby or, you know, the underarm of the baby. And use that as your anchor point to keep rotating the baby around. And there will come a point where the baby during this rotation, and it might be a huge one, I've rotated babies completely into a posterior position and they've been born as if they were born posteriorly. So they were born looking at their mother's pubic bone where it was previously facing me. So a full rotation where you track along the back of the baby's head so that you can find the back and then you're going to hook under the baby's armpit and don't pull don't hook onto that and pull you're going to hook onto that in order to push and rotate the baby around we're rotating not pushing and if you're familiar with some of the shoulder dystocia maneuvers this is kind of acting like a wood screw but with a single finger if you need to if this isn't working you can access the anterior shoulder and do, a full wood screw maneuver where you're completely pushing both shoulders around to add, but the posterior arm.
[1:14:35] Push still works failing that you could track up a little bit further if you need to sweep sweep i'm doing some actions if you're watching the video sweep the baby's arm in front of its head, to bring the posterior arm out as a way of creating space in the pelvis and then you dislodge the anterior shoulder.
[1:14:54] Now, the importance of tracking your hand up against the baby's back and then fighting the armpit is that you don't want to rotate the baby and open its chest. You want to kind of squish the chest in on itself to reduce the diameter of the shoulders. So you don't want to be pushing the shoulders back so the shoulder blades come together. You want to be pushing the shoulders together so the baby gets like cleavage and that's going to shrink the diameter of the shoulders. So that's why we've got to find the back and then sweep across to find the arm so that you know that you're rotating in the correct way, so if you track up from the baby's head you know you're going to end up at the baby's back and then the back of the posterior shoulder you're not going to enter from the front of the baby's chest towards its nipples so track from the back of the head you're going to meet the posterior shoulder hook under it rotate around towards the nipples and then you can corkscrew so you've just created a turn because there is room in the rest of the woman's pelvis and as you turn the baby will unhook from that spot that they're stuck on if you haven't already tried to pull the baby in impact it more, that will probably be enough to release the baby because that just you use the posterior space to rotate the baby not further impact it by pulling it.
[1:16:16] I think that this is hands down the number one least invasive method, highly effective. It usually works. You do not need to do an episiotomy in order to access that space. There's so much room you don't need to consider an episiotomy.
[1:16:32] And of course, although this should go without saying, anytime you want to do something to a woman, you need to first get her permission. Obviously, there is not much time. So the way that I do this in order to get permission in this kind of urgent situation is I'll say a phrase something like I feel like your baby needs help to get out because I think it's stuck in order to do that I need to put two fingers in your vagina, and do some maneuvers do I have your permission, and I can almost guarantee that the women will say yes if they don't this is the opportunity for external maneuvers you can say that's okay I can try some external ones but I may need to revert back to some internal ones but I will try the external ones first that don't require you to put your fingers in their vagina. But if they don't work you can explain. I've tried the maneuvers that I can do externally but they haven't worked. Your baby remains stuck and I would like to do some internal maneuvers. Do I have your permission to put my hand in your vagina?
[1:17:33] And this is how you can inform the woman, let her know how urgent it is. Your baby is stuck. I feel like I need to do something. I need to put my hands in your vagina and do some maneuvers in order to do that. It's one single sentence. We've got time for that.
[1:17:47] Wait for the yes and then go ahead. And if you remember nothing else from this episode, I want to suggest to you, if you are a midwife or an obstetrician, next time you're managing a shoulder dystocia, once you've diagnosed it and decided you need to act before anything else move the woman into a position that allows you to access the posterior space of her pelvis and the most evidence-based position for this is hands and knees and then with permission find the posterior shoulder by tracking behind the baby's head to find the back and then rotate the posterior shoulder until the baby clunks out from wherever it was stuck and just rotate it around until you can find the space in the pelvis for the shoulder to fit through and the vast majority of the time this will work, and remember if you are a midwife or an obstetrician and you want more education clinical guidance and research just like this what we've done today join me and a group of hundreds of other supportive clinicians as we navigate our work in the assembly of rebellious midwives you can get on the wait list in the show notes below and you'll be the first to know when the lifetime offer opens that I'll be given to 200 people and that will open in October, 2026.
[1:19:03] That has been today's episode of the Great Birth Rebellion podcast. We've been talking through some of the strategies of shoulder dystocia and there are so many papers and research about this in the resource folder. So if you're not yet on the mailing list and you want to have a look at that, just join the mailing list. The link is in the show notes.
[1:19:22] I'm Dr. Melanie Jackson and I will see you in the next episode of the Great Birth Rebellion podcast. cast.
[1:19:29] To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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